Please fill out the form below:

Name

Birth Date

Street Address

City     State    Zip

Phone number

Email address

Name of peace officer killed in the line-of-duty:


Officer's employing agency:


Officer's End of Watch date:


Your relationship to peace officer:


College or Business/Trade School of choice:

(Proof of Enrollment must be Faxed to 916-944-2171 for application to be considered)

Intended Major:


Intended Career:


G.P.A. at last school attended:

Have you previously applied for and/or received a scholarship from the California Peace Officers Memorial Foundation? If yes, please list dates and provide most recent transcripts:


In the space below, write a statement indicating why you feel you are deserving of a financial award.
This section must be completed.


All of the information provided in this application is true to the best of my knowledge and I have read and understand the award requirements: Yes No