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2. Name
3. Title
4. Length of Time in Office
6. Town
7. County
8. Population
10. Mailing Address
12. Telephone
13. Email
15. Pervious office(s)/service related positions

    Please include position title and dates held. Separate each position with a comma. 

17. NYSTCA Member

    Yes or No & Date

18. Attended a NYSTCA Conference?

    Include dates attended

20. IIMC Member?

    Yes or No & Date 

21. Attended a IIMC Conference?

    Include dates attended

23. Attended an approved IIMC Institute and/or academy?

    List name of academy and dates attended. 

25. Attended an IIMC Region 1 meeting?

    Include location and dates attended

27. Related organizations to which you belong:
29. Prior Education

    Please include any prior education from NYSTCA, Association of Towns, County Town Clerks Association and other

31. Are you an RMC?

    Please include dates of RMC and when/if your designation has been renewed 

33. Dues for Organizations

    Please list dues paid to organizations paid for by the Town and yourself. List the organization, the amount and who it is paid by

35. Does your Town Board currently allow or have previously allowed, educational expenses to you or other Town Officials?

    Explain actual financial expenses for education for the past 2 years: (List year and amount i.e. 2019/$75). Include details. You may upload a budget document using the file upload at the end of this form. Please indicate that you will be uploading a document by stating : Uploaded Document.

37. Current and previous budget allowances for education:

    You may upload a budget document using the file upload at the end of this form. Please indicate if you will be uploading a document by stating : "Uploaded Document."

    
    

39. Include itemized travel and educational expenses for the current and two previous years.

    You may upload a budget document using the file upload at the end of this form. Please indicate if you will be uploading a document by stating : "Uploaded Document."

    
    

41. Have you previously applied?

    1. Yes
    2. No
42. Award?

    Yes or No. Include dates received if yes or no. 

44. Brief description of why you are applying and need this scholarship:
46. Upload Budget Documents Here:

48. Please have the Supervisor submit a letter that includes the statement below on behalf of the Town Board indicating rather or not your Town will assume the balance of your costs for attendance at the New York State Town Clerks Conference. 

    I, _________________________________Supervisor of the Town of  ____________________ on behalf of the ___________________Town Board do hereby agree to assume all costs over and above the amount of the NYSTCA Scholarship Grant related to attendance of the _____________________  Town Clerk at the  2023 NYSTCA conference.  I also understand that membership in the NYSTCA is required in order to receive any scholarship.

    Or

    The Town of ________________ will not be paying the cost of attendance of the __________________ Town Clerk at the 2023 NYSTCA conference. 

    
    

50. Upload Letter from Town Supervisor:
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field