OMEGA PSI PHI FRATERNITY, INC.
SCHOLARSHIP COMMITTEE
P.O. BOX 1943
COLUMBIA, SC 29202
www.capitalcityques.com /
2017 Scholarship Application
Postmark Deadline: APRIL 21st, 2017
Instructions:
1. Please type in your information
2. Use “Tab” key to go to next field in form or use mouse, (Type...Tab. Type...Tab. Repeat as needed)
Select the applicable scholarship
Purple Scholarship – 3.5 or higher high school GPA
Gold Scholarship – 2.80 to 3.49 high school GPA
Part I: General Information
Last Name: First: Middle: Suffix:
Social Security Number: Date of Birth: Click here to enter a date.
Ethnic Identification: Gender:
Home Address: City: State: Zip Code:
Home Phone Number: Mobile#:
Email Address:
Parent Name’s/Legal Guardian’s Name: Parent’s Mobile#:
Parent Name’s/Legal Guardian’s Name: Parent’s Mobile#:
Education
Name of High School (HS):
HS Address: City: State: Zip Code:
Expected date of HS Graduation: Click here to enter a date.
Cumulative HS GPA: on a scale Class Rank: of SAT Test Score:
ACT Test Score: Expected College Major:
Name of College or University to which applicant has been accepted:
Name of College or University to which applicant has been accepted:
Applicant Name:
(Last, First, Middle Name, Suffix)
references
Name: (First, Last)
Home Address: City: State: Zip Code:
Home Phone Number: Mobile Phone Number:
Email Address:
Name: (First, Last)
Home Address: City: State: Zip Code:
Home Phone Number: Mobile Phone Number:
Email Address:
Name: (First, Last)
Home Address: City: State: Zip Code:
Home Phone Number: Mobile Phone Number:
Email Address:
Part II: Honors & Awards over the last 4 years
Community Service and Extracurricular Activities (Include Positions held. Please distinguish service from social activities):
Community Service:
Honors & Awards:
STATEMENT OF UNDERSTANDING
I hereby state that the information contained in this application is true and correct to the best of my knowledge at this time. I understand that any false information automatically disqualifies me from eligibility. I agree that the decision of Chi Iota Iota Chapter of Omega Psi Phi Fraternity, Inc. shall be final. I hereby acknowledge that all submitted materials become the exclusive property of Chi Iota Iota Chapter of Omega Psi Phi Fraternity, Inc. and will not be returned.
print Applicant’s name / Date______
Applicant’s Signature Date
print Parent’s/Legal Guardian’s name / Date______
Parent’s/Legal Guardian’s Signature Date
For additional information, please contact Troy Robinson at or at 803-360-8873.
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