Student Full Name: UTSA ID:

Preferred Name: Gender:

Email Address (the one you check daily)

Date of Birth: Birthplace: Ethic Background:

Permanent Address: City: State: Zip Code:

Cell Phone: Home/Alternate Phone:

U.S. Citizen? (Y/N) Permanent Resident? (Y/N) If Permanent Resident list A#:

Have you lived in Texas for the last 3 consecutive years?

High School Name: High School City: High School State:

Graduated High School with Diploma?(Y/N) GED? (Y/N) Graduation Year:

Test Scores
SAT Month/Year Taken: / ACT Month/Year Taken:
Reading / English
Math / Math
Writing / Reading
Science
Composite / Composite

College/University you currently attend or most recently attended:

Dates Attended:

Current Major: Intended Major at UTSA:

Current Cumulative Hours: Current Cumulative GPA: Member of Phi Theta Kappa?

Other colleges/universities physically attended: / Dates attended:
Other Colleges/ / Dates attended:

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Using round numbers, indicate below the number of transferrable credit hours you have earned in each category. The numbers entered equal the number of transferable credit hours indicated elsewhere on this application.

AP Dual Credit Online On Campus Total transferrable hours

Are you currently employed? (Y/N)

Please list employment history since high school, beginning with current employment
(no more than the past 10 years)

Employer / Position / Dates held (MM/YYYY) to MM/YYYY) / Employment Type
Have you served in any of the following military areas: / If yes, please list dates of service / Branch
Active Duty
National Guard
Reserves

Honorably Discharged? (Y/N) Wounded Warrior? (Y/N)

Please list permanent Duty Stations with dates:

Station Name / Station
City, State / Dates (MM/YYYY) to MM/YYYY)
Military Occupation Specialties (MOS):
Specialized Training:
Medals, Awards, and Honors:

Financial information may be subject to verification from tax returns and other sources)

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Section 5A: If you are married please complete this section. If you are not married, skip to section 5B.

Relation / First Name / Last Name / Student? / Last Year’s Federal Income Tax Adjusted Gross Income / Have you utilized military benefits? / Remaining benefits from GI bill or Hazelwood Act
Self / $ / GI Bill
Hazelwood
Spouse / $ / GI Bill
Hazelwood
Child 1
Child 2
Child 3
Child 4

Joint Adjusted Gross Income: $

Section 5B: Please complete if you are NOT married (single, divorced, and widowed). If you are a depended, include your parents)’, stepparent(s)’ or guardian(s)’ information below.

Relation / First Name / Last Name / Student? / Last Year’s Federal Income Tax Adjusted Gross Income / Have you utilized military benefits? / Remaining benefits from GI bill or Hazelwood Act
Self / $ / GI Bill
Hazelwood
Father / $ / GI Bill
Hazelwood
Mother / $ / GI Bill
Hazelwood
Sibling/child
Sibling/child
Sibling/child
Sibling/child

Parents’ Joint Adjusted Gross Income:$

Section 5C: Other Financial Assistance

Do you and/or your spouse receive child support? (Y/N) If yes, how much per month: $

Please describe any other financial resources that you rely upon to support yourself and your family:
Please describe any special circumstances that affect your family’s ability to fund your college expenses. (required)

Section 5D: Student debt and other financial information

Have you completed and submitted your FAFSA? (Y/N)

Do you have student debt? (Y/N) Amount of your student debt amount? $

Does your spouse have student debt? (Y/N) Amount of spouse’s debt amount? $

Do you and/or your spouse pay child support? (Y/N) If yes, how much per month? $

Do you pay the cost of childcare for your dependent children? (Y/N)
If yes, how much per month? $

Please describe any additional factors or circumstances demonstrating your financial need:

Section 6A: Extracurricular Activities, Organizations, and Leadership Positions

Please list up to six activities or organizations in which you have been most involved and indicate the leadership positions held and length of involvement or number of service hours completed.

Organization/Activity / Position / Service hours/length of involvement

Section 6B: Church, Community, and Volunteer Service

Please list up to six church, community, or civic organizations in which you have been most involved. Indicate the leadership positions held and the length of involvement or number of service hours completed do not repeat from section 6A.

Place or Name of service / Position / Service hours/length of involvement

Section 6C: Awards, Special Honors and Distinctions

In order of importance to you, list up to six major awards you have received in the past.

Award/Honor/Distinction / Basis of Award / Year(s) of Award

Please explain why you have chosen to apply to The University of Texas at San Antonio.

Why have you chosen your academic major?

What are your life’s goals and objectives?

Please write the following essays in a separate document, save them as a PDF and return them along with the application, letter of recommendation, and a PDF of official transcripts to .

1.  Essay Topic 1:

It has been our experience that all transfer students have a story to tell about their background and the road they have taken to get to this point. Some did not complete high school, but received their G.E.D. Some went directly from high school to college. Others went from high school into the military or work force. Still others describe a particular event, moment, or conversation when they discovered what they wanted to achieve and what they needed to do to accomplish their goals. Please tell us about the story of your journey to the decision to study at your chosen university and the lessons you learned along the way. 800 word limit

2.  Essay Topic 2:

Describe an example of your leadership. Be sure to describe your actions and the actions of those around you to explain what you accomplished. 800 word limit.

With the electronic signature below, I certify that the information I have provided is complete and correct to the best of my knowledge. If my application is accepted, I agree to abide by the policies, rules, and regulations of the Terry Foundation. I authorize The University of Texas at San Antonio and the Terry Foundation to verify the information I have provided. I further understand that this information will be relied upon by the Terry Foundation in determining my financial eligibility and that the submission of false information is grounds for rejection of my application and/or withdrawal of an offer of scholarship.

Applicant Electronic Signature: (Type full name)

Date signed: (MM/DD/YYYY)

In order for your application to be complete the following documents need to be attached to the email along with your application.

·  Essay 1

·  Essay 2

·  Letter of Recommendation

·  Official electronic transcript