OFFICE AND PROFESSIONAL EMPLOYEES INTERNATIONAL UNION
ROMEO CORBEIL MEMORIAL FUND
"SUMMER CAMP"

APPLICATION FORM
APPLICATION DEADLINE: April 30, 2004

Name of Applicant: ___________________________________________________________________
                 Last           First                 M.I.           Telephone

Home Address:   ___________________________________________________________________
                                            Street

___________________________________________________________________________________
           City                    State                         Zip Code

Date of Birth: ______________________ Sex: M ___ F ___ Soc. Sec. # _____________________
  (Must be between the ages of 13 and 16 only)

Member/Associate Member Name: ______________________________________________________
                                Last             First                 M.I.

Home Address:   ___________________________________________________________________
                                            Street

___________________________________________________________________________________
           City                    State                         Zip Code

Member/Associate Member Employed By: _______________________OPEIU Local Union ________

Relationship to Member/Associate Member: Son ___ Daughter ___ Other ______________________

If my child is selected for this scholarship, I fully agree to adhere to the rules that have been established by the Scholarship Committee.

Signature of Parent of Applicant _____________________________________ Date: ______________

Signature of Local Union President or Secretary-Treasurer:

_______________________________  Date: ___________________ Local Union Number _________

__________________________________________
       (Print name of signing officer)

The Summer Camp is held during August of each year, at University Forest Environmental Education Center, University of Missouri, Route 2, Box 139, Williamsville, MO 63967, (573) 222-8373, Fax (573) 222-8829.

SEND APPLICATION AND INQUIRIES TO:
Office and Professional Employees International Union
Romeo Corbeil Scholarship Fund "Summer Camp"
1660 L Street, N.W., Suite 801, Washington, D.C. 20036
Phone: (202) 393-4464 Fax: (202) 347-0649