You are on page 1of 9

Texas Exes Scholarship Foundation Chapter Scholarship Application

2012-2013 Academic Year


Important: If you are a recruited athlete, DO NOT include any information about your athletic participation or achievements on this application.

Personal Information
UT EID ______________________ Male Female

Name _________________ _________________ _________________ _________________ First Middle Last Preferred Email Address __________________________________________________________________ *Please list an email address that you will continue to use through the summer.* Permanent Address _____________________________________________________________ Street Address ________________________ City Home Phone ___________________________ ____________ State ________________ Zip Code

Cell Phone ___________________________

Academic Information
Have you been admitted to The University of Texas at Austin? Yes No

UT School/College ________________________________________________________ Major __________________________________________________________________ High School ___________________________________ Name _________________________ City SAT Total Score ___________ Reading ___________ Math ___________ Graduation Date ________________ _________________________ County

____________ Zip Code

ACT Total Score ___________ Class Rank _______ of _______ students # of students with this rank ___________ GPA _________ on a scale of _________

Writing ___________

Extracurricular Activities
In order of importance to you, list up to six extracurricular activities and the position(s) you held.

Organization/Activity

Position(s) Held

Year(s) 9th, 10th, 11th, 12th

Brief Description of Activity

Community or Volunteer Service


List up to six community or volunteer service organizations you were associated with, a brief description of the activity, total number of hours you volunteered, and when you participated in each activity. List your most recent activity first.

Place of Service

Brief Description of Service

Total Hours

Dates of Service From To

Awards
In order of importance to you, list up to four major awards, honors or distinctions that you received both in and out of school during grades 9-12.

Award/Distinction/Honor

Brief Description/ Basis of Acknowledgement

Year(s) Received 9th, 10th, 11th, 12th

Employment
Employment and Internships List all your current and previous jobs or internships. Include your employers name, job title, how many hours per week you worked, and the dates of employment. List your most recent job first.

Employer

Position/Job Title

Hours per Week

Dates of Service From To

Financial Information
Do you intend to apply for financial aid through the Office of Student Financial Services at The University of Texas at Austin during the academic year this scholarship would cover? Yes No Your parents marital status __________________ You presently live with (please check one): Both Parents Mother Father Father & Step Mother Mother & Step Father Other (please specify) ____________________ Father/Step Fathers occupation ____________________________ Father/Step Fathers employer _____________________________ Father/Step Fathers total annual income $____________________ Mother/Step Mothers occupation ___________________________ Mother/Step Mothers employer ____________________________ Mother/Step Mothers total annual income $___________________ Guardians occupation _____________________________________ Guardians employer ______________________________________ Guardians total annual income $_____________________________ Please provide information for all the children under 25 years of age in your family. Do not include yourself. Relation to You Age School/College/Occupation Year in School Self Supporting?

Special circumstances that affect your familys ability to fund your college expenses (please limit your response to less than 100 words).

Essay 1
Choose one essay option from the two listed below (please limit your response to less than 700 words). Option 1: Describe a significant setback, challenge or opportunity in your life and the impact that is has had on you. Option 2: Describe and evaluate one experience that significantly influenced your academic or personal interests. The experience might be a high school course, a job, a relationship, or an extracurricular activity. Be sure to explain how this experience led to you setting the goals you now have for you yourself.

Essay 2
Choose one essay option from the two listed below (please limit your response to less than 700 words). Option 1: Many students expand their view of the world during their time in college. Such growth results from encounters between students who have lived different cultural, economic, or academic experiences. With your future growth in mind, describe a potential classmate that you believe you could learn from either within or outside a formal classroom experience. Option 2: The core purpose of The University of Texas at Austin is to transform lives for the benefit of society. What do you hope to gain from your UT experience? What will you contribute to UT in return (i.e., how will your presence on campus benefit or improve the UT community)?

Statement of Verification/Release Authorization


I certify that the information I have provided is complete and correct to the best of my knowledge. I authorize the Texas Exes Scholarship Foundation to verify the information I have provided. I further understand that any scholarship funds that I am awarded from the Texas Exes Scholarship Foundation will be received only if I attend The University of Texas at Austin. Name _______________________________ Date _____________ UT EID ___________

Please mail or email to: Stephen A. Caldwell Texas Exes - Fort Bend County Chapter 2831 Cane Field Dr. Sugar Land, TX 77479 sacaldwell@alumni.utexas.net

You might also like