b'CSIA SCHOLARSHIP CSIA 9CSIA SCHOLARSHIP APPLICATION NameAddressCity, State, Zip CodeTelephone Number ( )E-mail AddressRelationship to CSIA Member Employee CSIA MEMBER INFORMATION Name of CSIA Member EmployeeEmployers NameAddressCity, State, Zip CodeTelephone Number( )Fax Number( )E-mail AddressEDUCATIONAL BACKGROUND High School NameAddressCity, State, Zip CodeTelephone Number( )Office Contact / Guidance CounselorCurrent Grade Point Average:out of ascaleExtra Activities, sports, clubs, achievements (use separate sheet if necessary)Probable Field of StudyEducational Goals (use separate sheet if necessary)Selected University, College, Training InstituteDate Classes Begin/ / Applicant SignaturePrint or type name and date Signature of Corporate Officer Print or type name and date Please include your 500-800 word essay and photo with this form when youreturn it by July 15th to the CSIA Office 7250 Poe Ave.Suite 410 -Dayton, Ohio 45414 csiaonline.org'