Received_______________

NATHAN MURPHY MEMORIAL SCHOLARSHIP

2008 APPLICATION FORM

Please type application (including essay) and return completed application to: Murphy Scholarship, Physical Therapy Specialists Clinic, P.O. Box 849, West Plains, MO 65775. Applications must be received in the West Plains clinic by 5:00 p.m. on February 22, 2008.

PERSONAL:
Name: _______________________________________________________________________________________
                                Last                                                                        First                                                        Middle
Home Address_________________________________________________________________________________
                                Street                                                                    City                                                         Zip
County__________________ Social Security No.______________________   Birth date _____________________

Daytime Phone: _________________ Evening Phone:___________________ Email: _______________________

Are you currently employed? _______ If Yes, name of employer______________________________

Work Address _________________________________________________________________________________
Street City Zip
What is your GPA or GED score? _________ Are you related to any law enforcement employees? ____________
If Yes, please indicate their name, relationship and in which County/City they work:

Juvenile______________________________________________________________________________________
                  Name                                                                    Relationship                                          County/City
Probation/Parole______________________________________________________________________________
                                   Name                                                   Relationship                                          County/City
Highway Patrol________________________________________________________________________________
                                Name                                                     Relationship                                         County/City
Sheriff_______________________________________________________________________________________

Office use only.

                 Name                                                                      Relationship                                         County/City
City Police____________________________________________________________________________________

                 Name                                                                   Relationship                                         County/City
Other________________________________________________________________________________________
                Position            Name                           Relationship                                          County/City

____/30

FINANCIAL:
What is your declared annual family income? _________________
Are you head of household? Yes / No How many dependents do you support? ________

____/20

COMMUNITY INVOLVEMENT:
Work Experience
Please list your prior work experience chronologically. (Attach list if needed)

_______________|_________________________________________|_____________________|_______________
Dates Employed Employer County City/State

____________________________________________________________________________________________
Job Title/Duties

_______________|_________________________________________|______________________|______________
Date Employed Employer County City/State

____________________________________________________________________________________________
Job Title/Duties

Page 2

Name: _______________________________ _______________________________
Last First

Have you volunteered with or do you have experience with public safety/law enforcement not listed above? _____
If Yes, please outline____________________________________________________________________________

_____________________________________________________________________________________________

Please list community involvement or volunteer work with dates.
_____________________________________________________________________________________________

_____________________________________________________________________________________________

____/40

ESSAY:
Please attach a typed, double spaced essay on “Why I want a career in law enforcement and where I expect to be in ten years.” (no more than three typed pages)

____/10

EDUCATION:
Please name the specific law enforcement school or college you are currently attending or will be attending and the enrollment date.

/100 POINTS

____/50

/150 POINTS

INTERVIEW: