2007 MARSHALL M. HICKS MEMORIAL SCHOLARSHIP ENTRY FORM
For sons and daughters of Michigan State Utility Workers Council, AFL-CIO, members and retirees
To be completed and mailed on or before January 1, 2006 to:
Marshall M. Hicks Memorial Scholarship Program
Michigan State Utility Workers Council, AFL-CIO
110 West Lenawee Street
Lansing, Michigan 48933

Please enter my name in the 2007 Marshall M. Hicks Memorial Scholarship Program. The program is open to students who will
complete high school and enroll full time in regionally accredited U.S. colleges in 2007 and who meet all other particpation
requirements specified by National Merit Scholarship Corporation (NMSC).

I will complete high school in 2007 and enroll full time in college in 2007: YES |__| NO |__|

The month and year I will complete high school is: __________ MONTH ___________YEAR

I am the |__| SON or |__| DAUGHTER of an active, retired, or active member who died on the job of Michigan State Utility
Workers Council, AFL-CIO.

|__| YES, I will take (took) the 2005 Preliminary SAT/National Merit Scholarship Qualifying Test (PSAT/NMSQT) on October
12 or 15, 2005. I understand that 2005 PSAT/NMSQT scores will be used by NMSC as an initial screen of applicants in the 2007
Marshall M. Hicks Memorial Scholarship Program.

(PLEASE TYPE OR PRINT)

Name of Applicant:________________________________________ ____________________________ __________

Last

First
 Middle Initial

Home
Address: ___________________________________________________________________________________________

Number and Street

City

State
 Zip Code
Gender: |__| |__| Birth Date: ______ - ______ - ______ Home Telephone Number: ___________________________

Male

 Female

 

  Month  Day  Year

High School You
Currently Attend: ____________________________________________________________________________________

EXACT NAME

City

State
 Zip Code

High School Where
PSAT/NMSQT Taken (if different) : _______________________________________________________________________

EXACT NAME

City

State
 Zip Code

Name of Parent |__| Father Local # to Which
Employed by |__| Mother Parent Belongs : ___________
Company: ______________________________________ |__| Stepfather  
  |__| Stepmother  

I further understand that the selection of scholarship winners and stipend payments will be handled by National Merit
Scholarship Corporation of Evanston, Illinois.

___________________________________  ________________   ___________________________________

Signature of Applicant

 Date

 Signature of Parent or Guardian
Member of Michigan State Utility Workers Council