2014 Gate City Chapter
Scholarship Application
TYPE OR PRINT ALL INFORMATION, EXCEPT SIGNATURES
Completeness and neatness ensures your application will be reviewed properly
Application postmark deadline is March 15, 2014
APPLICANT DATA
Last Name________________________ First Name________________________ Middle Initial_______
Mailing Address_______________________________________________________________________
City___________________________ State___________________________ Zip/Postal Code_________
Telephone (
) __________________________
Email Address_______________________________
Parent(s) Name_______________________________________________
Parent(s) Phone Number (
) __________________________
HIGH SCHOOL DATA
School Name_______________________
Expected Graduation Date______________________
Current Weighted Grade Point Average___________________
Test Scores: SAT Score (Critical Reading & Math Sections Only) ________________________
ACT Score _______________________
WORK EXPERIENCE (please feel free to use additional sheets of paper as needed)
Describe your work experience during the past four years. Indicate dates of employment for each
job and approximate number of hours worked each week.
Employer/Position
From – Mo/Yr
To – Mo/Yr
Hours per Week
ACTIVITIES, AWARDS AND HONORS (please feel free to use additional sheets of paper as needed)
List all extracurricular activities (in and outside of school) in which you have participated during the
past four years (e.g. student government, music, sports, volunteer work, scouts, etc). Indicate all
special awards, honors, and offices held.
Activity
# of
Years
Special
Awards,
Honors
Offices Held
Activity
# of
Years
Special
Awards,
Honors
Offices Held
GOALS AND ASPIRATIONS (please feel free to use additional sheets of paper as needed)
Make a brief statement or summary of your plans as they relate to your education and career
objectives and long-term goals.
UNUSUAL CIRCUMSTANCES (please feel free to use additional sheets of paper as needed)
Please describe how and when any unusual family or personal circumstances have affected your
achievement in school, work experience, or your participation in school and community activities.
APPLICATION CHECKLIST
The applicant is responsible for submitting all materials to the Gate City Chapter Scholarship
Committee on time. Incomplete applications will not be evaluated. This application becomes
complete and valid only when all of the following materials have been received.
□
□
□
Student Application
□
□
Letter of recommendation from teacher
Current Official High School Transcript
FAFSA form – Including Expected Family
Contribution (EFC)
Letter of recommendation from community
(must be non-relatives)
All materials must be addressed to:
Gate City Chapter
North Carolina A&T State University
Scholarship Committee
P.O. Box 20005
Greensboro, NC 27420
CERTIFICATION
The Gate City Chapter has the sole responsibility for selecting scholarship recipients based on criteria as
set forth in the program’s description. This application becomes the property of the Gate City Chapter,
(It is recommended you keep a copy for your files).
I acknowledge decisions are final. I certify I meet eligibility requirements of the program as
described in the guidelines and the information provided is complete and accurate to the best of
my knowledge. Falsification of information may result in termination of any award granted.
Applicants Signature______________________________________________________ Date____________________