PSSO Education Assistance Fund

Professional Support Staff Organization

Last Name of Applicant (required)

First Name of Applicant (required)

Middle Initial

WIN (required)

�� identification number

PSSO Member Name (required)

Address (required)

City (required)

State (required)

Zip (required)

Relationship to PSSO Member (required)

Self

Spouse

Other

If other relationship to member, please explain

Member's Department (Do not abbreviate) (required)

Semester Requesting Assistance (required)

Fall

Spring

Year Requesting Assistance (required)

Member Participation in PSSO Committees (Be specific and include year)

Member Participation in PSSO Activities (Be specific and include year)

I hereby agree to terms of the application. This will also serve as my signature. (required)

Agree

Disagree