PHI BETA KAPPA ASSOCIATION OF MAINE

      ACADEMIC ACHIEVEMENT AWARD SELECTION FORM
           FOR 2016 - 2017 ACADEMIC SCHOOL YEAR



NAME OF JUNIOR STUDENT SELECTED____________________________________________

(print name clearly; it is being printed in calligraphy on a certificate)

NAME OF HIGH SCHOOL_________________________________________________________

FULL SCHOOL ADDRESS__________________________________________________________

______________________________________________________________________________

CONTACT PERSON_______________________________TELEPHONE_______________________

CONTACT PERSON'S EMAIL ADDRESS_______________________________________________

ASSEMBLY DATE*_______________TIME_____________LOCATION_______________________

*When the award would be bestowed upon the Junior, if applicable.  Please indicate whether you would like a PBK Association representative to make the presentation.  This is not always possible; however we have been able to accommodate many of these requests with enough notice.

Please return this form by Friday, April 7 via email or regular mail to:

Debora Elliott Ward, Awards Committee Chairman
PBK Association of Maine
94 Otis Street
Bangor, ME 04401
Tel:  207 973 6349
email:  delliotward@emhs.org





© Phi Beta Kappa of Maine
Powered by Wild Apricot Membership Software