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

Banner ID

U.S. Citizen:

Please Indicate Your Minority Group

Other (Please Specify)

Academic Information

Name of High School

Telephone: School

HS Graduation Date

Achievement Test/Score

GPA

Class Rank

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)

Select File

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

Education (Check one):

Father's Occupation

Education (Check one):

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

Upload

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.

 
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DeSoto, TX. 75115

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Tel: 972-841-1457