2012 Blutillion

Participant Application
Sponsored by Zeta Phi Beta Sorority, Incorporated
Tau Phi Zeta Chapter
Canton, Mississippi
An unofficial high school transcript, two (2) letters of recommendation must accompany all applications, 2.5 grade
point average and a nonrefundable $35 money order. At least one recommendation should be from an academic
official. Deadline for submission of these items is January 18, 2012.
Participant Information:
Name: ______________________________________________________ Telephone: _______________________
First

Middle

Last

(Area Code) Number

Mailing Address:
_____________________________________________________________________________________________
Street

City

State

Zip

Sex: ____________ Birthday: ______________________ E-Mail: _______________________________________

Month / Day / Year

Parents Information:
Mother: ______________________________________________________ Telephone: ______________________
(Area Code)

Number

Mothers Address ______________________________________________________________________________

Street

City

State

Zip

(If different from students mailing address)

Mothers Email: ______________________________________ Daytime Telephone: ________________________
(Area Code)

Number

Father: __________________________________________________ Telephone: ___________________________

(Area Code)

Number

Fathers Address _______________________________________________________________________________

Street

City

State

Zip

(If different from students mailing address)

Fathers Email: _______________________________________ Daytime Telephone: ___________________
(Area Code)

Number

Education:
High School: _______________________________________________________
Address: _____________________________________________________________________________________
Street

Grade Level: ________

City

GPA: ______

State

Zip

2012 Blutillion
Participant Application
Community Involvement:
Extra Curricular Activities: _______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Honor Awards: ________________________________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

Recognitions: _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Church Involvement: ____________________________________________________________________________

____________________________________________________________________________
____________________________________________________________________________

DEADLINE: January 18, 2012

All application packages must be turned in by the deadline date. Incomplete packages will not be accepted. If you
have any questions or concerns, you may contact us by emailing tpzblutillion@gmail.com or 601-750-3940.

Disclaimer and Signature

By signing my signature below, I certify that my answers are true and complete to the best of my knowledge. If this
application leads to being selected as a participant for the Tau Phi Zeta Chapter of Zeta Phi Beta Sorority, Inc.
Blutillion, I understand that false or misleading information in my application may result in my release from the
2012 Blutillion.
____________________________________

____________________________

Applicants Signature

Date

_____________________________________________
Parent/Guardian Signature

___________________________________
Date

2012 Blutillion
Participant Application
Essay
Briefly tell us about yourself, describing future goals, ambitions, interests, and etc

2012 Blutillion
Participant Application

Tau Phi Zeta Chapters 2012 Blutillion

Personal Reference Form
to be completed by January 18, 2012
This form is a confidential document to be completed by your personal reference and mailed, faxed or
delivered to the Blutillion Committee by January 18th.
Name of Participant: _________________________________

Phone Number: _________________________

Type of Relationship (circle appropriate response (s))

Close Personal Relationship

Sports Contact

Church Contact

School Contact

Work Contact

Volunteer Contact

TO THE BLUTILLION PARTICIPANT:

Please provide this personal reference form to someone who knows you very well (e.g. teacher, counselor,
employer, minister, etc.) but is not a family member. Please do this as soon as possible so the form is received by
the Blutillion Committee prior to the application deadline of January 18th. Please follow up with your personal
reference before the deadline to make sure your reference form was completed and mailed, faxed or delivered.
The form is confidential and must be returned by your personal reference. Please affix a stamp to an envelope and
give this to your personal reference so he/she may mail it to the following address:
Zeta Phi Beta Sorority, Inc.
Tau Phi Zeta Chapter
Attn: Blutillion Committee
P. O. Box 171
Canton, MS 39046

Form may be faxed to: 866-336-5742

(Please be sure to fax both pages)

TO THE PERSONAL REFERENCE:

The Blutillion participant has applied for the 2012 Blutillion. This reference will be confidential. Please fill out the
information on the following page and return it to the Blutillion Committee by January 18th (see address above).
Please mail, fax or deliver the completed form in self addressed envelope provided by the participant and sign your
name.
Personal Reference Name: ____________________________________________ Date: _____________________
(Please print or type)

Phone Number: __________________________________

___________________________________________________
Signature

2012 Blutillion
Participant Application

Tau Phi Zeta Chapters 2012 Blutillion

Personal Reference Form
to be completed by January 18, 2012
This form is a confidential document to be completed by your personal reference and mailed, faxed or
delivered to the Blutillion Committee by January 18th.
Name of Participant: _________________________________

Phone Number: _________________________

Type of Relationship (circle appropriate response (s))

Close Personal Relationship

Sports Contact

Church Contact

School Contact

Work Contact

Volunteer Contact

TO THE BLUTILLION PARTICIPANT:

Please provide this personal reference form to someone who knows you very well (e.g. teacher, counselor,
employer, minister, etc.) but is not a family member. Please do this as soon as possible so the form is received by
the Blutillion Committee prior to the application deadline of January 18th. Please follow up with your personal
reference before the deadline to make sure your reference form was completed and mailed, faxed or delivered.
The form is confidential and must be returned by your personal reference. Please affix a stamp to an envelope and
give this to your personal reference so he/she may mail it to the following address:
Zeta Phi Beta Sorority, Inc.
Tau Phi Zeta Chapter
Attn: Blutillion Committee
P. O. Box 171
Canton, MS 39046

Form may be faxed to: 866-336-5742

(Please be sure to fax both pages)

TO THE PERSONAL REFERENCE:

The Blutillion participant has applied for the 2012 Blutillion. This reference will be confidential. Please fill out the
information on the following page and return it to the Blutillion Committee by January 18th (see address above).
Please mail, fax or deliver the completed form in self addressed envelope provided by the participant and sign your
name.
Personal Reference Name: ____________________________________________ Date: _____________________
(Please print or type)

Phone Number: __________________________________

___________________________________________________
Signature

2012 Blutillion
Participant Application
Personal Reference Form
to be completed by January 18, 2012
Participants Name: ______________________________________________
1. What is your relationship with the participant? _____________________________________________________
2. How long have you known the participant? ___________________________
3. Please circle for each characteristic:
a) Character and
personality

Poor

Fair

Good

Excellent

Outstanding

b) Initiative and
drive

Poor

Fair

Good

Excellent

Outstanding

c) Interaction with
others

Poor

Fair

Good

Excellent

Outstanding

d) Leadership
demonstrated

Poor

Fair

Good

Excellent

Outstanding

e) Concern for
others

Poor

Fair

Good

Excellent

Outstanding

f) Team Player

Poor

Fair

Good

Excellent

Outstanding

How do you think the participant will benefit from participating in the Blutillion?

Additional comments:

Thank you for your time and effort. Be assured that the information you supply will be kept in the strictest
confidence. Please return this form by January 18th.

If you have any questions, please call Dina Smith, (601) 750-3940.

2012 Blutillion
Participant Application
Personal Reference Form
to be completed by January 18, 2012
Participants Name: ______________________________________________
1. What is your relationship with the participant? _____________________________________________________
2. How long have you known the participant? ___________________________
3. Please circle for each characteristic:
a) Character and
personality

Poor

Fair

Good

Excellent

Outstanding

b) Initiative and
drive

Poor

Fair

Good

Excellent

Outstanding

c) Interaction with
others

Poor

Fair

Good

Excellent

Outstanding

d) Leadership
demonstrated

Poor

Fair

Good

Excellent

Outstanding

e) Concern for
others

Poor

Fair

Good

Excellent

Outstanding

f) Team Player

Poor

Fair

Good

Excellent

Outstanding

How do you think the participant will benefit from participating in the Blutillion?

Additional comments:

Thank you for your time and effort. Be assured that the information you supply will be kept in the strictest
confidence. Please return this form by January 18th.

If you have any questions, please call Dina Smith, (601) 750-3940.