Membership Program Scholarship Application - Arkansas Criminal Justice Institute Arkansas Criminal Justice Institute

Date of Application *

What year are you applying for a scholarship? *

Agency Head's Rank/Title/Position *

Agency Head's Name *

First Last

Agency Head's Email Address *

Agency Head's Cell Phone *

Agency Phone Number *

Agency Extension

Agency Name *

Agency Address *

Street Address Address Line 2 City State ZIP

Agency County *

Population Served *

Type of Agency *

Total Number of Employees *

Is your Agency currently paying for training? *

Scholarship Need Justification *

Please provide specific justification for your request.