1.     School ______________________________________________________________
 

        Chapter name ________________________________________________________
 

2.     Nominating ______________________________________________(student name)

3.     We have verified that the total hours graded and earned at our institution are ____________ quarter  or __________

        semester (not including transfer hours, assessment hours, CLEP credit and the like).

4.     We have verified the cumulative grade point average for our institution to be  ________________.

5.      We have verified that the enclosed faculty recommendation and evaluation form are from a qualified instructor at  this

          institution.  ___________ (check)

6.     We have verified that the nominee will need undergraduate degree assistance of at least the face

         amount of the scholarship at our institution in the 2002-03 academic year. ____________ (check)

7.     We have verified that all materials are included ______. (check)

8.     Information established by ______________________________________________.  Date ____________
                                                                (National Councilor Name)
 

                    (title) ______________________________________________________
 

                (signature) ____________________________________________________

                   Address ____________________________________________________

                                 ____________________________________________________

                                 ____________________________________________________

                              Phone (     ) ____________________________________________

                    E-mail _____________________________________________________