KPSC Entrepreneurial Opportunities Group Application

ENTREPRENEURIAL OPPORTUNITIES GROUP
SCHOLARSHIP APPLICATION

E-mail Address:	(you are responsible to update KPSC/EOG on any change in e-mail address)
Date:
Last Name:
First Name:
Middle Name:
Date of Birth:	mm/dd/yyyy
Permanent Address:
Apartment:
City, State Zip:	State Zip
Phone:
University Address:
University Apartment:
City, State Zip:	State Zip
University Phone:
I am currently:	3P 4P 5P Other
Currently a Member of NCPA Student Chapter at KU?	Yes No
If Yes, date joined	Month Year
Briefly describe your post graduate career plans:

I certify that the information given on this application is true and accurate to the best of my knowledge.
Please submit no later than October 16, 2009. Applications will not be accepted after that date.

1020 SW Fairlawn Road, Topeka, KS 66604 | Ph: 785.228.1695 Fax: 785.228.9147