Prairie View A&M University

Establishment of a University Scholarship

PART 1

Please advise the University regarding establishing guidelines for this scholarship by completing the information below:

1. / Yes, the University may establish scholarship guidelines. (Please sign and return to the address below).

Name of Scholarship Donor

Print Name: / PVA&MU Class of 1957
By Clemon H. Wesley / Title: / President
Signature: / Date: / May 1, 2006
Address: / P.O. Drawer 60 Prairie View, TX 77446
2. / X / No, the scholarship donor(s) will establish guidelines (Please complete part II, III, IV and return to the address below).
3. / X / Request further discussion with university officials by
X / Office Visit (Requested date and time) / Perpetual
X / Phone Call (Request date and time) / Perpetual
X / Mail (Request response by) / Perpetual

If you checked number three (3) you will receive a follow-up immediately so that we may finalize a discussion time as requested above.

Mail to:

University Scholarship Administrator

Prairie View A&M University

P. O. Box 337

Prairie View, Texas 77446

Prairie View A&M University

Establishment of a University Scholarship

PART 2

Scholarship Donor’s Name: / Class of 1957 / Date: / 03/27/06
Name of the Scholarship: / Class of 1957 Academic Achievement Fund
Scholarship Description
This scholarship is established as indicated below (check appropriate designation):
X / Endowment Scholarship – use only the interest earned for scholarship awards. The principal will not be used.
Cash Scholarship – use the actual cash amount deposited to award scholarships.
Provide a brief description of the person(s) for who (whom) the scholarship is named:
N/A
Provide a brief description of the organization (foundation, company, association, etc.) for which the scholarship is named.
Class of 1957
Scholarship Management
Total Dollar Amount of the Scholarship / $75,000 est. +matching 1:1 funds
Indicate any limitations on the number of scholarships that may be awarded during a semester: / Up to 5
Indicate total dollar amount that each student may receive for each semester: / $1,000
Indicate total dollar amount of scholarship award that may be offered for scholarship recipients each semester: / $4,500
Special Instructions: / Student will be selected annually and awarded up to $375 per semester
Based upon required academic eligibility throughout the course of the year.

Scholarship Criteria

PART 3

Name of Scholarship

/ Class of 1957 Academic Achievement Fund / Account Number
Academic Year of Coverage /
College/Department
Instructions
Please check all criteria applicable for an individual to satisfy requirements for the scholarship listed above. Criteria must be used for academic year. Changes cannot be made until the beginning of the next academic year.
Who may apply? / Freshman / Sophomore / Junior / Senior / All
Major / Minor
Major GPA / Minor GPA
Semester GPA / 3.0 / Cumulative GPA
Semester Hours / Cumulative Hours
High School Cumulative GPA / 3.5 / SAT / 1000 / ACT / 20
County, Texas, U. S., Foreign
Extracurricular Activities
Parent(s) are graduates of Prairie View A&M University
First Child to Attend College
Armed Services / Army / Navy / Other / Veteran
Participation in Co-op/Intern Placement
Relative Employed by Company (Specify)
Special Talent (e.g. Art, Music, Drama) (Specify)
Ethnicity / Male / Female
Program/Organizational Participation (e.g. Social/Church/Association)
Need based or lack of financial resources, low income family
Other – Specify all other requirements not covered above
College/Department Scholarship Manager / Date
Dean of College / Date

Scholarship Report

PART 4

1. / The scholarship donor is not requesting a scholarship report.
2. / X / The scholarship donor is requesting a scholarship report. Describe the information that you would like to have in the report.

Name of scholarship recipients; amount awarded annually; account balance

Business Address for the Scholarship:

Frank T. Hawkins, Treasurer

Business Address: / Drawer 60
City: / Prairie View
State: / Texas
Zip Code: / 77446
Phone No.: / 936.857.3538

Name of Scholarship Donor: PVA&MU Class of 1957

Scholarship Managers: / Clemon H. Wesley, President
Dr. Samuel Metters, 1st Vice President (Fundraising)
Dr. Frank Hawkins, Treasurer
Signature of Donor or Official Establishing the Scholarship:
Name: / PVA&MU Class of 1957 by Clemon H. Wesley / Title: / President
Leave Blank
Internal Use Only
Date Scholarship Established: / Account No.:
Signature Authority on this Account: / Title:
Scholarship Administration Review: / Title:
Presidential or Designee Review: / Title: