AlphaKappa Alpha Sorority, Inc.

Zeta Psi Omega Chapter

Versie L. Williams Memorial Scholarship

Versie L. Williams Memorial Scholarship Application
This application may be photocopied.
2016 SCHOLARSHIP APPLICATION
PERSONAL DATA
1. Last Name: ______/ First Name: ______/ Middle Initial:_____
2a. Street Address: ______
2b. City: ______/ Louisiana / Zip: ______
3a. Daytime Phone: ______/ 3b. Evening Phone: ______
3c. Cellular Phone: ______/ 3d. e-mail: ______
4a. Date of Birth: ______/ Place of Birth: ______
5a. Sex: ____ Male ____ Female / 6b. Marital status: ____ Single ____ Married ____ Other
6. Citizenship Status: ____ U.S. Citizen ____ Permanent Resident ____ Student Visa
7. Name and address of the school you will be attending in the fall of 2016:
______
______
______
8. Current year in school: / High School Senior: ____ yes ____ no
Expected date of graduation: ______
Date of Senior Awards Program: ______
9. Anticipated Major: ______/ Degree: ______
10. Current GPA: ______/ ACT Score: ______Date taken: ______
11. Your plans upon graduation from college: ______
______
______
______

12. Extracurricular Activities

List all extracurricular activities including skills and hobbies. Describe briefly any activity not well-known. (use additional paper if necessary)

______

13. Distinctions, honors and awards

Indicate the basis of selection for any award that is not well known. (use additional paper if necessary)

______

14. References. List two adults who best know your academic qualifications, including academic performance, potential, and motivation. One of the references must be a faculty member who has known you for at least two years.

Name / Address / Position & Institution / Telephone #

TO BE COMPLETED BY A SCHOOL REPRESENTATIVE.

Name ______/ Title ______/ Telephone ______
Applicant’s Name ______High School ______
1. Applicant’s Cumulative GPA ______Class size _____ Class rank _____
If a rank is not available, please approximate the student’s position
to the nearest tenth percent and / or provide a grade distribution for the class.
2. Is this student eligible for the TOPS program? ____ Yes ____ No
______/ ______
Signature of School Official / Date

FINANCIAL DATA (2016)

Both income and expenses must be completed before the application can be considered.

Estimated expenses for school year / Estimated income
Tuition and fees $ / College Savings $______
Books and supplies / Expected earning
Housing / Support from parents
Food / Grants (PELL, etc.)
Personal items / Loans
Transportation / Work study
Other expenses / Scholarships
Spouse’s income
Other income
TOPS ______
Public Assistance ______
Total Expenses $ ______/ Total Income $ ______

TO BE COMPLETED BY PARENT OR GUARDIAN:

Father’s name: ______/ Occupation:______/ Gross Income: $ ______
Mother’s name: ______/ Occupation:______/ Gross Income: $ ______
Spouse’s name: ______
(if married) / Occupation:______/ Gross Income: $ ______
Last Year’s Adjusted Gross Income from IRS Form 1040 $______# Exemptions Claimed _____
Father’s Return / Mother’s Return / Joint Return(If divorced or separated, please provide information on both parents)
Last Year’s Adjusted Gross Income from IRS Form 1040 $______# Exemptions Claimed _____
Father’s Return / Mother’s Return / Joint Return(If divorced or separated, please provide information on both parents)

Name(s) and age(s) of persons dependent on parents/spouse’s income:

1.

2.

3.

If you are self-supporting student, list name(s) and age(s) of dependents, if any.

1.

2.

2016VLW Scholarship

Please attach a passport quality photo below.

Please sign below as required.

1.I understand that the attached photograph may be used to promote the Versie L. Williams Memorial Scholarship and other programs made possible by Alpha Kappa Alpha Sorority, Incorporated - Zeta Psi Omega Chapter.

2.Are you a dependent (daughter, son, step-daughter or step-son) of a member of Alpha Kappa Alpha Sorority, Inc.?

_____Yes_____ No

3.We certify that the information we have provided is true and complete to the best of our knowledge. If required, we agree to provide proof of this information, including but not limited to copies of income tax returns. We realize that if documentation is not provided, the Applicant may be deemed ineligible for this scholarship.

By signing this application you understand that if you purposely give false or misleading information this award may be revoked. Repayment of any amounts received may be required.

______/ ______/ ______
Applicant Signature / Parent / Guardian Signature / Date

ESSAY

Describe the key ways that you have been able to achieve success both academically and socially. In your essay, include a discussion of some of the major obstacles you have faced and how you have been able to overcome them.

PLEASE TYPE

TWO PAGE (MAXIMUM)

DOUBLE SPACED

12 PT. TIMES NEW ROMAN FONT

1” MARGINS

1