Application
Fill out all information in the boxes
Name of Applicant
Address of Applicant
Telephone: Home
Work / Cellphone
Fill out all information in the boxes
Academic Year (20__ - 20__)
Name of Applicant
Address of Applicant
Telephone: Home
Work / Cellphone
Date of Birth
Social Security #
Email Address
Email Address
U.S. Citizen:
Please Indicate Your Minority Group (Required)
Other (Please Specify)
Academic Information
Name of High School
Telephone: School
HS Graduation Date
GPA
Class Rank
Achievement Test/Score:
SAT
ACT Combined/Comp
Anticipated Major
Anticipated Undergraduate Graduation Date
High School Counselor
Attach Copy of Transcript(s)
(Add all transcripts if attended more than one high school)
List any other schools attended
(Separate schools by comma)
Personal Information
(Please List)
1) School Related Activities
(Separate activity by comma)
2) Honors and Achievements
(Separate by comma)
3) Hobbies, Talents, and
Special Interests
(Separate by comma)
4) What is your primary career goal?
5) If you intend to enroll in graduate/professional School, what is the highest degree you would like to achieve?
Degree
Discipline
Financial Aid Information
If you are considered a dependent student, please indicate the approximate annual income of your family.
Do you anticipate receiving any of the following awards? (Check all that apply)
Have you been awarded any other scholarships or grants? (List Name, Type and Amount)
Do you plan on working to help cover the expenses of your education?
If yes, approximately how much of your expenses will you pay?
Mother's Occupation
Father's Occupation
Do you have any brothers or sisters in College? If so, please give the following information.
Name
Institution
Year
Major
Please submit a LETTER OF RECOMMENDATION
In the space provided below, please type how the Chuck Burch Scholarship will make a difference in your ability to become academically and professionally successful.
Fill out all information in the boxes
Academic Year (20__ - 20__)
Name of Applicant
Address of Applicant
Telephone: Home
Work / Cellphone
Date of Birth
Social Security #
Email Address
Email Address
U.S. Citizen:
Please Indicate Your Minority Group (Required)
Other (Please Specify)
Academic Information
Name of High School
Telephone: School
HS Graduation Date
GPA
Class Rank
Achievement Test/Score:
SAT
ACT Combined/Comp
Anticipated Major
Anticipated Undergraduate Graduation Date
High School Counselor
Attach Copy of Transcript(s)
(Add all transcripts if attended more than one high school)
List any other schools attended
(Separate schools by comma)
Personal Information
(Please List)
1) School Related Activities
(Separate activity by comma)
2) Honors and Achievements
(Separate by comma)
3) Hobbies, Talents, and
Special Interests
(Separate by comma)
4) What is your primary career goal?
5) If you intend to enroll in graduate/professional School, what is the highest degree you would like to achieve?
Degree
Discipline
Financial Aid Information
If you are considered a dependent student, please indicate the approximate annual income of your family.
Do you anticipate receiving any of the following awards? (Check all that apply)
Have you been awarded any other scholarships or grants? (List Name, Type and Amount)
Do you plan on working to help cover the expenses of your education?
If yes, approximately how much of your expenses will you pay?
Mother's Occupation
Father's Occupation
Do you have any brothers or sisters in College? If so, please give the following information.
Name
Institution
Year
Major
Please submit a LETTER OF RECOMMENDATION
In the space provided below, please type how the Chuck Burch Scholarship will make a difference in your ability to become academically and professionally successful.