2004 TED BRICKLEY AND BERNICE F. SHICKORA
SCHOLARSHIP AWARD

Please complete this application form and forward with items 4, 5, 6, and 7 to:

NJ Chapter ASSE 2003 Ted Brickley and Bernice Shickora Scholarship
Liberty Mutual Insurance Co.,
Attn: Frank Gesualdo,
3 Becker Farm Rd., 2nd Floor,
Roseland, NJ 07068

Applications will be accepted through April 30, 2004. The Review Committee may invite selected candidate(s) to an interview prior to selecting the winner.

Applicant's Name _____________________________________  Date ____________________
School Address ______________________________________ School Phone ____________________
City _________________________________________________ State _______ ZIP _________
Home Address ______________________________________ Home Phone ____________________
City _________________________________________________ State _______ ZIP _________
ASSE - Member _____________________________________ Member #  __________
Relationship to ASSE Member _____________________________________
  1. Class Standing (Check One)

    2. ____ Freshman

    ____ Sophmore

    ____ Junior (60 to 90 semester hours completed)

    ____ Senior (90 to 120+ semester hours completed)

    ____ Graduate

  2. What degree or major work-study are you enrolled (or will be enrolled) in?
    Please specify ___________________________________________________________________

  3. Are you a member of any association(s)?

    _____ Yes (please list membership(s) __________________________________________________

    _____ No

  4. Provide a brief biography of your interests, hobbies, and/or work experience. Include any significant accomplishments and any extracurricular activities you believe the Review Committee should know. A copy of a current resume will satisfy this request.

  5. Submit a copy of your current transcript.

  6. Submit a reference letter to the Chapter from the relative associated with the ASSE.

  7. Submit to the Chapter a letter of reference from a High School Teacher, the University’s Department Head, a Professor or a Supervisor at a current job.