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A. Brian Simmons Scholarship
Established by Mr. Simmons' colleagues in recognition of his outstanding
thirty-seven year commitment to the education of students in School District No. 79.
Application Form
Please type or print all information except signature.
ELIGIBILITY _____________________________________________ ______________________________________________________________________ __________________
Last Name Other (in order)
_____________________________________________ ______________________________________________ __________________
Permanent Residence Address City, Province Postal Code
_____________________________________________ ______________________________________________ __________________
Mailing Address (if different from above) City, Province Postal Code
(250) _______________________________ (250) _______________________________ _____________________________________
Home Telephone Cell Telephone E-Mail Address (if available)
Date of Birth _______ / _______ / _______ ____________________________________ Date of Graduation _______ / _______
Year Month Day Social Insurance Number Month Year
_____________________________________ ____________________________________ (250) _______________________________
School Principal Telephone
Check the box to the left to indicate that the following documents are attached to this application form.
signed declaration form, specific to this scholarship, available from a school counselling office, indicating the years and schools attended
photocopy of proof of Canadian citizenship or landed immigrant status
CONDITIONS _____________________________________________ ______________________________________________ __________________
Preferred Canadian University First Year Program Entry Date (Year)
Check the box to the left to indicate that the following documents are attached to this application form. _______________________________
brief, typewritten, laser printed letter indicating your future educational and occupational goals Career Goal
QUALIFICATIONS Check the box to the left to indicate that the following documents are attached to this application form.
current, certified, full transcript of marks indicating: marks from the previous year of study, marks for courses completed to date in the present school years, and interim marks for courses in progress
_________________________________________________________ ___________________________________________________________
Second Language Last Teacher (or Other Person to Verify Proficiency)
For details of the following, see a copy of your school’s Scholarship & Bursary Manual.
_____________________________________________ __________________________________ ______________________________
Qualifying Leadership Activity Position Teacher or Sponsor
_____________________________________________ __________________________________ ______________________________
Qualifying Other Service Activity Position Teacher or Sponsor
_____________________________________________ __________________________________ ______________________________
Qualifying Athletic or Fine Art Activity Position Coach, Teacher or Sponsor
_____________________________________________ __________________________________ ______________________________
Qualifying “Other Regarding” Community Service Activity Position Agency or Organization Officer
_____________________________________________ __________________________________ ______________________________
Qualifying Part-Time Employment Position Employer
Check the box to the left to indicate that the following documents are attached to this application form.
letter of reference from an officer of a community agency or organization, indicating the nature and extent of the volunteer service provided
letter of reference from a representative of a professional or corporate employer, indicating the nature of the work, the length of employment, the hours of work and the level of commitment to the performance expectations of the employer
confidential, sealed letter of reference from the school principal or vice principal, indicating the administrator's level of support for this application
In signing this application you are indicating that you understand that if you are the recipient of this scholarship, in order to receive the scholarship, you must:
▪ be accepted into and register as a full-time student in a recognized, full first-year program of a degree granting, publicly funded, Canadian university in the year the award is made
▪ provide a certified copy of your provincial graduation certificate
▪ provide the scholarship trustees with a graduation photograph (grad photo)
And that the scholarship in the amount of $1000 will be paid to the recipient
▪ one half upon proof of paid registration for the first term at a public Canadian university
▪ one half upon proof of paid registration for the second term
And that the scholarship trustees reserve the right to modify any of the qualification requirements within the original purpose of the scholarship.
_________________________________________________________ ___________________________________________________________
Applicant’s Signature Date
School Attended
Grade 10 ______________________ Grade 11 ______________________ Grade 12 ______________________ G P A ____________
Challenge of Graduation Program ___________________________________________________________________________________________
Trustee Recommendation _________________________________________________________________________________________________
H:\Forms\AB Simmons Scholarship Application\Application Form.doc REVISED: 14-05-10
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ACCEPTANCE
CONDITIONS
TRUSTEE’S
REVIEW
Applicants are asked not to make entries in this area.
What can you use as proof of citizenship to Canada? a certificate of naturalization or a certificate of citizenship is accepted as proof of citizenship. There are ways persons born or naturalized in Canada or born outside Canada to a Canadian parent could lose citizenship. See the Loss and acquisition section. See also: Citizenship Certificates.
