DELTA PHI UPSILON FRATERNITY, INCORPORATED
Iota Chapter - Houston, TX
BAYARD RUSTIN SCHOLARSHIP APPLICATION
APPLICANT INFORMATION
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth
*
Current Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Telephone Number
*
Format: (000) 000-0000.
What Is Best Time To Call?
*
Daytime
Nighttime
Email Address (All email notices will be sent to this address)
*
example@example.com
ACADEMIC INFORMATION
Current Classification:
*
Graduating High School Senior
College Freshman
College Junior
College Sophomore
College Senior
1st Year Postgraduate
2nd+ Year Postgraduate
Anticipated Graduation Date:
*
Name of Current School
*
Location (City, State)
*
GPA:
*
On 4.0 Scale
Name of Intended School
*
Upload College Acceptance Letter
*
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What Is Your Intended Major?
*
What Is Your Degree Program?
*
What Are Your Career Goals?
*
EXTRACURRICULAR INFORMATION
EXTRACURRICULAR INFORMATION
Rows
School Organization
Position Held
Year
1
2
3
4
5
Community/Social Organization Memberships (Include positions held if applicable, year, and number of service hours completed)
Rows
Community/Social Organization
Position Held
Year
Hours
1
2
3
4
5
Major Awards/Honors (Include any awards or honors that you have received, and year)
Rows
Award
Awarding Organization
Year
1
2
3
You may upload ONE (1) page of additional extracurricular information.
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FINANCIAL INFORMATION
Have you applied for OR are you receiving other financial aid/scholarships or support for the upcoming academic year?
*
No
Yes
Have you applied for the Bayard Rustin Scholarship Award in previous years?
*
No
Yes
Have you been awarded the Bayard Rustin Scholarship Award in previous years?
*
No
Yes
SCHOLARSHIP INFORMATION
Please provide short answers to the following questions.
How did you hear about the Bayard Rustin Scholarship?
*
How would you benefit from the Bayard Rustin scholarship?
*
Why/how will you benefit from a college education?
*
List the names of your two recommenders and how you know them.
*
Please write your 300-500 word essay in the space below.
*
In describing himself, Bayard Rustin once wrote: “The principal factors which influenced my life are 1) nonviolent tactics; 2) constitutional means; 3) democratic procedures; 4) respect for human personality; and, 5) a belief that all people are one.” Which of these qualities do you think that you share with Bayard Rustin, and how have you put it into action to positively influence others?
RECOMMENDATIONS
All applicants must submit one academic OR professional AND one personal letter of recommendation.
Academic/Professional Recommendation
*
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Personal Recommendation
*
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PROFESSIONAL PHOTOGRAPH
One professional headshot should be submitted for use in official press releases and other fraternal publications. By submitting your photograph, you agree to allow it to be used. All photographs submitted become the property of Iota Chapter - Delta Phi Upsilon Fraternity, Inc.
PROFESSIONAL HEADSHOT
*
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CERTIFICATION
By my signature below I affirm that I plan to pursue my education beyond the high school level or that I am already enrolled at an institution of higher learning. If selected as a recipient of the Bayard Rustin Scholarship Award, I agree that my photograph can be used by Delta Phi Upsilon Fraternity, Inc. or its chapters, for official fraternity purposes. I affirm that the information contained herein is true and accurate to the best of my knowledge. I understand that falsification of information on this application or any supporting documentation will result in my disqualification from consideration for the Bayard Rustin Scholarship Award. I agree that if it is later determined that the Bayard Rustin Scholarship was awarded to me based on false information provided in this application or its supporting documents, I will repay the full amount of the award to the Delta Phi Upsilon Fraternity, Inc., or the awarding chapter.
Applicant Name:
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
CHAPTER/NATIONAL OFFICE USE ONLY
Date Received:
Received By:
Date of Interview:
Documents Received:
Acceptance Letter
Transcript
Photograph
Reference Letter #1
Reference Letter #2
Application Decision:
Approved
Not Approved
Incomplete
Ineligible
Notes
Preview PDF
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