Texas Jaycee Foundation

College Scholarship Program

Application Form

The Texas Jaycee Foundation will award scholarships on a "need" basis to persons wishing to enroll in an accredited Texas college, university or technical school. All scholarships will be awarded to applicants that meet the following requirements and can prove their need on this written application.

Fill out, print and mail this form to the address given along with all needed documentation and copies, etc.

Members of the Texas Jaycees Foundation Board of Directors, their families, including their Father, Mother, Spouse, Children and Grandchildren, are ineligible as recipients.

This program is intented to provide a service to our community and its citizens. Four scholarships will be awarded annually based on the applicant's financial need, community involvement and personal goals and aspirations.

Deadline for submission is the second Monday of January of any year. Any application received with a postmark later than this date will NOT be considered. Applicant is REQUIRED to submit five (5) copies of this application and five (5) copies of any substantiating material.

I. SCHOLARSHIP APPLICATION

Name of Applicant:

Home Address:

City: State: Zip Code:

Home Phone Number:

Social Security Number:

High School Attended:

High School Address:

Father's Name:

Father's Address:

Father's Occupation:

Father's Employer:

Mother's Name:

Mother's Address:

Mother's Occupation:

Mother's Employer:

Do you have a Step-Parent or Guardian other than your Parent(s)? No Yes

If yes, what is their Name and Address:



List, in chronological order, the names of your brothers, sisters or other persons dependent upon your Parents for support:
Name: Age:
Relationship:

Name: Age:
Relationship:

Name: Age:
Relationship:

Name: Age:
Relationship:

What is the name of the college or university you plan to attend:

What is the college or university's address:


Have you been accepted: Yes No

If yes, attach a copy of the acceptance letter.

APPLICANT'S FINANCIAL STATEMENT

The financial contribution of the applicant toward his or her own application is an important consideration in awarding this scholarship. The committee does not wish to penalize those students whose industry and careful planning have been a consideration in planning college attendance.

INCOME
Savings To Date: $_______.___
Expected Summer Earnings: $_______.___
Expected Contribution From Parents: $_______.___
Earnings From Part-Time Work: $_______.___
Money From Other Sources (including gifts from friends, relatives, education insurance, other scholarships, loans, etc.): $_______.___
TOTAL ESTIMATED INCOME $_______.___

EXPENSES
Tuition And Incidental Fees: $_______.___
Room And Board: $_______.___
Books And Supplies: $_______.___
Clothing: $_______.___
Incidental Expense (including various miscellaneous expenses such as travel, recreation, etc.): $_______.___
TOTAL ESTIMATED EXPENSES $_______.___

II. LEADERSHIP POSITIONS AND OFFICES

List, by name and by year, leadership positions and offices held and the approximate time commitment each month for school, church, community and volunteer activirties.

III. MEMBERSHIPS

List, by name and by year, memberships and other participation and the approximate time commitment each month for school, church, community and volunteer activities.

IV. HONORS AND AWARDS

List, by name and by year, the honors or awards you have received.

V. EMPLOYMENT

List the name and addresses of employers, including family business or self-employment. Indicate whether part-time or summer full-time with the hours per month you worked.

Name:

Address:

Name:

Address:

VI. REFERENCES

You MUSTinclude, up to five (5), letters of reference. Include one from your employer or, if not employed, an official of your current school. Include one from a civic or community leader. Others may be included from educators, clergy or other community leaders.

VII. TRANSCRIPT

A copy of your current transcript MUST be included with this application.

VIII. PERSONAL STATEMENT

Write (type or print or use this form) a paragraph (100 to 300 words) indicating your chosen field of college study. State your reasons for this choice. Include pertinent experiences, activities and accomplishments. Attach your personal statement to this application form.

IX. SUBMISSION INSTRUCTIONS

Staple all sheets together at the upper left hand corner and mail all items to:

The Texas Jaycee Foundation

College Scholarship Program

P.O. Box 1102

Pasadena, TX 77501-1102

The submission deadline is the second Monday in January of any year.. Any application received with a postmark after this date will not be considered.

X. SIGNATURE

I certify that all information supplied in the Scholarship Application are true to the best of my knowledge. The Texas Jaycee Foundation is authorized to verify any information contained in this application with the understanding that the information will remain confidential. I understand that any falsification or misrepresentation will result in disqualification.

Applicant's Signature:

________________________________________________________

Date: _____________________

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