SCHOLARSHIP APPLICATION

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SCHOLARSHIP APPLICATION

OMEGA PSI PHI FRATERNITY, INC. PSI PHI CHAPTER
This application is for African American male senior(s) in the Winston-Salem Forsyth County School System. This scholarship will be presented to the Awardee on a one-time basis. Information should be Typed and Printed in Black Ink, Legibly and Completely No Attachments. Everything must be concisely completed in the assigned fields within this original document. Only the Awardee will be notified. Postmarked Deadline is Friday, April 11, 2025. The award must be claimed at the Senior Award ceremony at the respective school where the awardee attends High School.
STUDENT BIOGRAPHICAL PROFILE
Last Name
First Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Apt #
City
State
Zip
Email Address
example@example.com
Birth Date

MonthDayYear
MotherFatherBoth ParentsGuardian
Student Employment
Company
Position
Supervisor
Phone
Format: (000) 000-0000.
ACADEMIC PROFILE
High School of attendance
Course of study
Planned College/University
Major
The information requested below must be obtained from your Official TRANSCRIPT & Official CollegeBoard website documents.

SAT Total Score

ACT Composite Score

Quality Point Average (weighed)

Class Rank
FAMILY PROFILE
Number of family members residing in the residence
Father's (Guardian) Name
Last Name
First Name
Address
Apt#
City
State
Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EmployedSelf-employedNot employedRetired
Employment/Company
Position
Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's (Guardian) Name:
Last Name
First Name
Address
Apt #
City
State
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Zip
EmployedSelf-employedNot employedRetired
EmploymentCompany
Position
Supervisor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Below $14,999$15,000-$24,999$25,000-$34,999$35,000-$44,999$45,000-$54,999$55,000-$64,999$65,000-$74,999$75,000-$84,999$85,000-$94,999$95,000-$104,999$105,000-Above
SCHOOL ACTIVITIES
List school activities in which you have participated during your junior and senior years (e.g. student government, clubs, music, sports, etc.). Indicate special awards and honors. List leadership positions and offices held. Check year(s) during which you participated in school activities. All information must be contained within this table, No Attachments.

Rows	Activity	School Sponsor/Advisor	Sponsor’s Phone Number	Special Awards/ Honors	Offices Held	Junior Year	Senior Year
.
.
.
.
.
.

COMMUNITY AND VOLUNTEER SERVICE ACTIVITIES
List community and volunteer activities in which you have participated or recognition for outstanding achievement or service without pay during your junior and senior years (e.g. Red Cross, Big Brother/Big Sister, youth group, church, volunteer at a nursing home, recycling project, etc Indicate special awards and honors. Check year(s) during which you participated. All information must be contained within this table, No Attachments.

Rows	Service Organization	Contact Person's Name	Contact's Phone Number	Special Awards/ Honors	Offices Held	Junior Year	Senior Year
.
.
.
.
.
.

6 What do you expect to gain from your college experience
7 Explain your financial need for this Scholarship
NOTARIZED RELEASE/AGREEMENT
I acknowledge the information given on this application to be the truth. I grant the Fraternity the use of my name, photograph, and other information provided in this application for purposes of news, publicity, publication, and all current and future promotions of this program. This application must be NOTARIZED.

Notary Public:
I, {lastName} {firstName} a notary public of Forsyth County, N.C., do hereby certify that the applicant and parent/guardian appeared before me this day and acknowledged the content of this application to be true. Witness my hand and notarized seal, {date58} this day of {date60}, 2024.
Applicant Signature

Clear
Date

MonthDayYear
Date
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Notary Signature

Clear
Date

MonthDayYear
Date
Notary Commission Expiration Date

MonthDayYear
Date
APPLICATION PACKET CHECKLIST
Typed & Printed Application
Wallet Size Photo (2.5” x 3.5”) Student in Cap & Gown attire or Coat & Tie (print name on back)
Transcript an official copy bearing School Seal Placed in a business envelope seal and secure by the Official School Stamp
ACTSAT score report from website
The application, photo, and transcript should be placed in a 9x12 envelope.
CATALOG ENVELOPE, BROWN (SIZED 9" X 12") TO:
TO

PSI PHI CHAPTER OF OMEGA PSI PHI FRATERNITY, INC.
P.O. Box 21271
WINSTON-SALEM, NC 27120
www.psiphichapter.com

PSI PHI CHAPTER OF OMEGA PSI PHI FRATERNITY, INC.

WINSTON-SALEM, NC 27120
WINSTON-SALEM, NC 27120
The Awardee will be presented a SCHOLARSHIP AWARD LETTER by mail and/or recognized on highschool Award, Class or Senior Day. The monetary award will be presented to Awardee after receipt of financialproof to the post-secondary school of acceptance. Electronic applications are available at the Psi Phi chapter’swebsite: www.psiphichapter.com

All questions should be directed to Terry Colaire (Scholarship Chairman) at 336-341-7393 ortcolaire@gmail.com.
Should be Empty:

Preview And Complete The Form Online, Then Download And Print It.

SCHOLARSHIP APPLICATION

STUDENT BIOGRAPHICAL PROFILE

ACADEMIC PROFILE

FAMILY PROFILE

SCHOOL ACTIVITIES

COMMUNITY AND VOLUNTEER SERVICE ACTIVITIES

NOTARIZED RELEASE/AGREEMENT

APPLICATION PACKET CHECKLIST

CATALOG ENVELOPE, BROWN (SIZED 9" X 12") TO:

WINSTON-SALEM, NC 27120