Wisconsin department of public instruction precollege scholarship program




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Wisconsin Department of Public Instruction

VERIFICATION OF ATTENDANCE

IN THE PRECOLLEGE SCHOLARSHIP PROGRAM

PI-1573-A (Rev. 05-12)



INSTRUCTIONS: Complete 10 days after the end of your program and return to:

WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION

PRECOLLEGE SCHOLARSHIP PROGRAM

Attn: MARY LOU HYATT

125 SOUTH WEBSTER STREET

P.O. BOX 7841

MADISON, WI 53707-7841







I. GENERAL INFORMATION







Precollege Program Name

     


Begin Date mm/dd/yy

     


End Date mm/dd/yy

     





This attendance was related to the precollege scholarship award(s) made earlier to these student(s). Please itemize award amounts per recipient.




Student Name
Please Alphabetize by Last Name

Birthdate
mm/dd/yy

Scholarship Amount




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     




     

     

     







II. SIGNATURES







I CERTIFY that the information provided on this application is true and correct to the best of my knowledge.




Name

     


Title/Position

     





College/University

     


FAX Area/No.

     


Telephone Area/No.

     





Signature



Date Signed mm/dd/yy

     








FOR DPI USE ONLY







 Approved  Approved as amended  Pending  Disapproved




Signature of DPI Official Responsible for Verification



Date Signed mm/dd/yy

     





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