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2022 ROBERT SHELTON & HARSH MODI SCHOLARSHIP APPLICATION
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2022 ROBERT SHELTON & HARSH MODI SCHOLARSHIP APPLICATION.

 

________________________________________                    _______________________

Last Name                       First                     Middle                            Pilot Certificate Number

 

________________________________________                    _______________________

Present Street Address               City         State    Zip                       Home Telephone Number

 

________________________________________                    _______________________

Permanent Street Address          City         State        Zip                       Birth Date and Place

 

________________________________________                    _______________________

E-mail Address                                                                           Cell or another Phone Number

 

________________________________________                    ________________________

 Applicant’s Employee & Supervisor                                         Supervisor’s   Position               

 

Average Number of hours worked per week ____

 

________________________________________                    ________________________

Employer’s Address                                                                   Employer’s Phone Number

 

________________________________________                    ________________________

If under 18 yr., Full name of Parent/Legal Guardian                 Relationship

 

________________________________________                    ________________________

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.

____________________________________________________________________________________________________________________________________________________________

 

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

_______________________________________________________________________ _______________________________________________________________________

_______________________________________________________________________

 

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.

 

 

___________________________________________                       ___________________

Signature                                                                                          Date

 

________________________________________________________________________

Print Name

 

________________________________________________________________________

If under 18 years of age, signature of parent or legal guardian

 

________________________________________________________________________

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