2022 ROBERT SHELTON & HARSH MODI SCHOLARSHIP APPLICATION.
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Last Name First Middle Pilot Certificate Number
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Present Street Address City State Zip Home Telephone Number
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Permanent Street Address City State Zip Birth Date and Place
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E-mail Address Cell or another Phone Number
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Applicant’s Employee & Supervisor Supervisor’s Position
Average Number of hours worked per week ____
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Employer’s Address Employer’s Phone Number
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If under 18 yr., Full name of Parent/Legal Guardian Relationship
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Address of the above referenced individual Telephone Number
FAA Certificates: List all certificates, including dates received and type of aircraft flown Include copies of all pilot certificates, BFR, endorsements and copies of the last 2 pages of activity from logbook.
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Total Time ________ PIC _________ Dual __________ within Last 6 Months ________
Education Background:
Highest Academic Degree __________________________________________________
Name of Academic Institution _______________________________________________
Graduation date (or expected graduation) ______ Students: # of hours per term ________
Include copies of diploma or transcripts.
Written Exam score and date passed for commercial rating ________________________
Robert Shelton & Harsh Modi Scholarship Application—Page 1 of 4
FLORIDA GOLDCOAST CHAPTER 99s
ROBERT SHELTON & HARSH MODI SCHOLARSHIP APPLICATION.
I certify that I am a current member of the Ninety-Nines, Friend of the Ninety-Nines or Veteran
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If Member of the Ninety-Nines International Women’s Pilot Organization indicate chapter affiliation ______________________________________________________________
Neither the Florida Goldcoast Chapter of the Ninety-Nines, Inc., its members, agents or representatives, are responsible for, nor liable for, the quality of any training, incident, or any other event which may occur while the recipient of the Robert Shelton & Harsh Modi Scholarship in performing training or activities relating thereto.
The applicant signature below indicates agreement to this disclaimer and declares that the information given in this application is true and correct. The applicant understands that this Scholarship will only be used for the purpose for which the applicant is applying.
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Signature Date
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Print Name
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If under 18 years of age, signature of parent or legal guardian
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Print Name
To apply, please complete this form and email it to flynlowe@comcast.net by October 15, 2022.
Robert Shelton & Harsh Modi Scholarship Application—Page 2 of 4
Robert Shelton & Harsh Modi Scholarship Application
LETTER OF RECOMMENDATION FORM
NAME OF THE APPLICANT__________________________________________________
The above applicant is applying for above 99s Chapter Scholarship. We would request that you complete this form and email it by 15 October 2022 to:
Kimberly Lowe
flynlowe@comcast.net
1.How long have you known this applicant and in what capacity?
2. How would applicant utilize this scholarship successfully, if awarded?
3. Relationship to Applicant. ________________________________________________________________________
4. Tell us in your own words why she should be considered as a candidate for this scholarship. We consider your opinion an important part of the selection process.
(Add additional pages to your comments as needed)
YOUR NAME_________________________________________PHONE__________
SIGNATURE____________________________________________DATE__________
Robert Shelton & Harsh Modi Scholarship Application—Page 3 of 4
ROBERT SHELTON & HARSH MODI SCHOLARSHIP APPLICATION.
Offered through
FLORIDA GOLDCOAST CHAPTER OF THE NINETY-NINES SCHOLARSHIP PROGRAM
CERTIFICATION
NAME OF THE APPLICANT______________________________________________
If I receive this scholarship, I will schedule and complete the written tests within one year after the date of receipt of the award. I also understand that I will be required to attend the Florida Goldcoast Chapter of the 99s, Scholarship Awards and Holiday party, to be presented with this Scholarship award by a representative of the Robert Shelton & Harsh Modi Scholarship.
SIGNED____________________________________________DATE_____________
FLORIDA GOLDCOAST CHAPTER NINETY-NINES HOLD HARMLESS AGREEMENT FOR THE SCHOLARSHIP APPLICANT.
Neither the Florida Goldcoast Chapter of the Ninety-Nines, Inc., or the South East Section of the Ninety-Nines, Inc., The Ninety-Nines, Inc., Pilot Training Center Homestead, Yogini Modi and Bryan Shelton, nor their members, agents, or representatives are responsible for the quality of any training received with this scholarship, or for any accident, incident, or any other event which may occur while the recipient of this scholarship is performing training or activities relating thereto. Recipient shall sign this Hold Harmless Agreement in favor of said entities upon receipt of the scholarship and before any training is made.
SIGNED_____________________________________________DATE_____________
Robert Shelton & Harsh Modi Scholarship Application—Page 4 of 4