APPLICATION FOR COLLEGE SCHOLARSHIP Sponsored by AFRICAN AMERICAN CHAMBER OF COMMERCE In Partnership with the Law Firm of BULLIVANT HOUSER BAILEY, P.C. PERSONAL INFORMATION Name: Address: Telephone: Fax: E-mail: Date of Birth: _ Parents or legal guardian: Name Address Phone Number EDUCATION High School: List all high schools and years of attendance: Name of High School Year Completed Year of graduation, or current grade: _ Cumulative grade point average: Guidance counselor: Name Phone Number Page 1 of 6
Activities, clubs, sports, and name and phone number of supervising faculty/coach: Name Type of Activity Phone Number Awards or recognition: College Attendance: Please provide information below for all colleges you have attended: Name of College Dates of Attendance Total Credit Hours Course of Study Cumulative grade point average: Guidance counselor: Name Phone Number Activities, clubs, sports, and name and phone number of supervising faculty/coach: Name Type of Activity Phone Number Page 2 of 6
Awards or recognition: Please attach copies of transcripts from all colleges attended. EMPLOYMENT HISTORY For the past two years, state the name of each employer, address or location, job position held, dates of employment, reason why the employment ended, and the name and telephone number of your manager or immediate supervisor. 1. 2. 3. PERSONAL REFERENCES List below three personal references. Please request each personal reference to fill out one of the attached Personal Reference Forms, and attach it to this application. Name Address and Phone Number Years Known Page 3 of 6
COLLEGE PLANS Identify the college you plan to attend and intended course of study or degree: Number of credit hours you intend to pursue each quarter: Name and telephone number of the person with whom you have made contact at the college regarding your admission and/or course of study: What other scholarships, if any, will you be receiving to attend this college? Will you be employed and working while you attend this college? If so, where? What are your career goals in the immediate future and in the long term? Immediate Future: Long Term: Page 4 of 6
ADDITIONAL INFORMATION Please provide the Scholarship Committee with any additional information you wish to have considered. PERSONAL STATEMENT Please provide a two-to three-page personal statement addressing why you believe you should be awarded this scholarship based on your commitment to your community, including volunteer work, church activities, community service projects, clubs, associations, and your plans for future involvement in your community. Also, please list the names and telephone numbers of the supervising adult for each affiliation. Page 5 of 6
CONDITIONS OF SCHOLARSHIP I understand that this scholarship is for attendance at an accredited, post secondary institution for higher education. I understand that a high school grade point average of 2.5, or a first year college minimum grade point average of 2.75 is a minimum requirement for scholarship eligibility. I understand that scholarship recipients must carry a minimum of 12 credit hours per quarter. I am of African American descent. I understand scholarship funds will be paid directly to the college. I agree the African American Chambers of Commerce and/or Bullivant Houser Bailey, P.C. may publicize the award of a scholarship to me. I understand and am willing to be interviewed by the Scholarship Committee. I certify that the above information is true to the best of my knowledge. Applicant s signature: _ Date: Mail this completed application, with transcripts, personal statement and completed personal reference forms to: Scholarship Committee c/o Bullivant Houser Bailey, P.C. 888 SW 5 th Avenue, Suite 300 Portland, OR 97204 *Note: Applications will be reviewed based on various criteria including thoroughness of your request. Page 6 of 6
COLLEGE SCHOLARSHIP PROGRAM Sponsored By AFRICAN AMERICAN CHAMBERS OF COMMERCE In Partnership with the Law Firm of BULLIVANT HOUSER BAILEY, P.C. PERSONAL REFERENCE NO. 1 For Name of reference: Address: Telephone Number: _ E-mail: How long have you known the applicant? Please describe your relationship to the applicant: Please state why the Scholarship Committee should award a scholarship enabling this Applicant to attend college, and provide any other information about the Applicant s character, background, accomplishments or community involvement which should be considered by the Scholarship Committee (please use additional sheets of paper, if necessary):
COLLEGE SCHOLARSHIP PROGRAM Sponsored By AFRICAN AMERICAN CHAMBERS OF COMMERCE In Partnership with the Law Firm of BULLIVANT HOUSER BAILEY, P.C. PERSONAL REFERENCE NO. 2 For Name of reference: Address: Telephone Number: _ E-mail: How long have you known the applicant? Please describe your relationship to the applicant: Please state why the Scholarship Committee should award a scholarship enabling this Applicant to attend college, and provide any other information about the Applicant s character, background, accomplishments or community involvement which should be considered by the Scholarship Committee (please use additional sheets of paper, if necessary):
COLLEGE SCHOLARSHIP PROGRAM Sponsored By AFRICAN AMERICAN CHAMBERS OF COMMERCE In Partnership with the Law Firm of BULLIVANT HOUSER BAILEY, P.C. PERSONAL REFERENCE NO. 3 For Name of reference: Address: Telephone Number: _ E-mail: How long have you known the applicant? Please describe your relationship to the applicant: Please state why the Scholarship Committee should award a scholarship enabling this Applicant to attend college, and provide any other information about the Applicant s character, background, accomplishments or community involvement which should be considered by the Scholarship Committee (please use additional sheets of paper, if necessary):