100 Black Men of West Texas, Inc.

www.100bmwt.webs.com

2014 Scholarship Application

Submission deadline: March 17, 2014
Please print or type legibly in ink. Include your transcript; a recent photo; and a letter of recommendation

Name: ______________________________________ Social Security # ______________________ Gender: Male ____ Female ___ Age: ______ Date of Birth: _______________________ Address ________________________________City ____________ State _______ Zip Code_______ High School Name: ____________________ Graduation Date:______ Phone: _________________ Grade Point Average________ [weighted: yes___ no ___] Include a copy of your school transcript. SAT Score: _____________ ACT Score: _________ Fathers Occupation______________________ Mothers Occupation__________________________ Raised by: Parent(s) _____; Grandparent(s) _____; Other family member(s) _____; Guardian _______ Number of Children in Family_____________ Total Family Income (check one - this will not effect eligibility but is needed for statistical purposes): ____ below $15,000; ____$15-$25,000; ____$25-$35,000; ____$35-50,000; ___Above $50,000 List Extracurricular Activities (use a separate sheet if necessary) _______________________ _______________________ ___________________ ______________ List Offices Held, Honors Received, Special Awards, etc. (use separate sheet if necessary) _________________________________________________________________________________ Have you applied for college financial aid? Yes / No (circle one); Type of Assistance___________________________ Amount $___________________ College of Acceptance (if applicable) _______________________________________________; or Colleges which you applied: ______________________________________________________ ESSAY: On a separate sheet or document, explain in your own words why you desire to pursue higher education and why you feel you need financial aid in this endeavor. (1 page limit) DECLARATION: I certify that I am currently a high school student who will graduate in the Spring or Summer. I understand that I must maintain full-time college student status to continue to be eligible for this scholarship. Scholarship funds may be distributed in half amounts for the school year (half each semester). If selected to receive this scholarship, I further understand that I must maintain a C average (2.0) for the first semester to be eligible for the balance of funds. I certify that the information that I provided above is correct and accurate. I further understand that if any information that I have submitted herein is determined to be false, I will be disqualified from further participation in this program. Signature: ____________________________________ Date: __________________

Application Due date is March 17, 2014. Send completed application to 100 Black Men of West Texas P.O. Box 6331 Lubbock, TX 79493. For more information call J. Leon Williams at (806) 773-1663.

APPLICATION CHECKLIST: The following items must accompany your application:

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School Transcript that includes your grade point average SAT and/or ACT Scores (Most transcripts will include this information. If your actual score is higher than what is reflected on your transcript, include a copy of your official scores. A complete essay A letter of reference from a teacher, former teacher, counselor or from an adult who is knowledgeable of your academic and extracurricular activities.

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A recent photograph of yourself (A photo taken within the last 10 months is needed for media purposes

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Sign and date your application. Deliver or postmark application on or before March 17, 2014.

(Revised & effective 1-8-14)