Please answer each section of
the application form completely. Copy & Paste in Word & type
the information in.
A. STUDENT INFORMATION
Last Name:
First Name:
Middle Initial:
Preferred First Name:
School ID:
Permanent Address:
City:
State:
Zip Code:
Phone Number:
Cell Phone Number:
Preferred e-mail:
Alternate e-mail:
Birthplace –
City:
State/Country:
Date of Birth:
U.S. Citizen:
Texas Resident: Gender:
Intended College Major:
Parent/Guardian Name:
Work Number:
Cell Number:
B. HIGH SCHOOL INFORMATION
High School Name:
City: Garland Zip:
High School Counselor:
Phone Number:
E-mail Address:
GPA (unweighted):
Class Rank: out
of students
# tied for this rank:
Valedictorian:
Graduation Date:
Admissions Tests: (You may superscore the SAT)
SAT ACT
Critical Reading: Composite score:
Math: SAT Equivalent (to be filled in by UTD):
Composite Score (CR/Math
only):
Indicate the level of recognition you have achieved in
the following scholarship program(s):
National Merit:
National Achievement:
National Hispanic:
C. ADVANCED
PLACEMENT, INTERNATIONAL BACCALAUREATE PROGRAM OR DUAL CREDIT COURSEWORK TAKEN
IN HIGH SCHOOL (attach additional pages if necessary)
Course
Name
|
AP/IB/Dual
Credit
|
Grade
Earned (if available)
|
Year
(sophomore, etc.)
|
D. ACTIVITIES, AWARDS AND EMPLOYMENT
Extracurricular Activities and Leadership Positions
List your top five
extracurricular activities (band, clubs, affiliations, etc.), the position(s)
you held and the year(s) of involvement.
Organization/Activity
|
Position(s)
held
|
Brief
description of activity
|
Year(s)
(please
underline)
|
FR SO JR
SR
|
|||
FR SO JR
SR
|
|||
FR SO JR
SR
|
|||
FR SO JR SR
|
Community/Volunteer Service
Describe your community
and/or volunteer service. List your most
recent service first.
Organization
|
Description
of Involvement
|
Hours per Week
or Total Hours
|
Dates of
service
|
Employment, Internships and Summer Activities
List your previous and
current jobs or internships. Include
your job title, employer’s name, how many hours per week you work or worked,
and the dates of employment. List your
most recent activity first.
Position/Job
Title
|
Employer/Name
of Organization
|
Hours per Week
|
Dates of
employment
|
Awards, Special Honors and Distinctions
List any major awards, honors
or distinctions you received, in order of importance during high school.
Award/Honor/Distinction
|
Description/Basis
for Award
|
Year
Received
|
E.
COLLEGE PLANS
Why have you chosen to apply to ________________________________?
Please list up to five universities to which you have
applied or plan to apply:
Why have you selected your academic major(s)?
Please describe your future goals and objectives
(include any educational, post-baccalaureate plans):
F.
FINANCIAL INFORMATION
Financial Information may be subject to verification
from tax returns or other sources.
Please be as accurate and complete as possible.
If your parents are married, please include
information for both parents. If they
are divorced, please only include information for the parent that claims you on
their tax return. If the parent that
claims you on his/her tax return is remarried, please include information for
the step-parent as well.
Your marital status:
Parent’s marital status:
Father/Stepfather’s occupation:
Mother/Stepmother’s occupation:
Father/Stepfather’s employer:
Mother/Stepmother’s employer:
Father/Stepfather’s total annual income:
Mother/Stepmother’s total annual income:
Family’s total annual income:
Your total annual income: $
Total college funds saved by you/others: $
Projected parental support (annual): $
Parents’ total cash savings (not limited to college): $
Value of parents’ other investments: $
Do you have a Texas Tomorrow Fund or 529 college savings
plan? Y N
If yes, what is its value:
Net value of your parents’ businesses, farm(s) and/or
ranches: $
Are you receiving financial assistance (such as Social
Security disability) from any local or federal government entity? Y N
If yes, please indicate the type of assistance and amount
received per month:
Parents’ Adjusted Gross
Income (AGI) for the most recent
year: $
Number of people in your household:
Number of siblings
Name and age of siblings:
Do you have a sibling who is a current/past Terry Scholar or
who is applying for a Terry Scholarship?
Y N
First in your family to attend college
Number of family members attending college in _year going to college__ (include
yourself):
Special circumstances that affect your family’s
ability to fund your college expenses (please use additional pages if
necessary)
---------------------------------------------------------------------------------------------------------------------------------------
UNIVERSITY/3rd PARTY SCHOLARSHIP
INFORMATION
**Please note that outside or 3rd party
scholarships may affect your need-based aid
List other scholarships or
grants you will receive for the college academic year:
Scholarship or Grant Name: Amount
per year:
Scholarship or Grant Name: Amount
per year:
Please note: To be considered for a Terry Foundation Scholarship,
applicants must file a Free Application for Federal Student Aid (FAFSA) with
the U.S. Department of Education and indicate The __________________as a report recipient.
The FAFSA can be filed on line at www.fafsa.ed.gov beginning January
1st. You must file your FAFSA no later
than March 15th for consideration for the Top 10% Scholarship.
I certify that the
information I have provided is complete and correct to the best of my
knowledge. If my application is
accepted, I agree to abide by the policies, rules, and regulations of the Terry
Foundation. I authorize UT Dallas and/or
the Terry Foundation to verify the information I have provided. I further understand that this information
will be relied upon by the Terry Foundation in determining my financial
eligibility and that the submission of false information is grounds for
rejection of my application and/or withdrawal of an offer of scholarship.
Applicant Signature: Date:
(Unsigned applications will not be considered)
ESSAYS
Attach a typed essay for each
of the topics listed below. Please ensure your full name and School ID appear
legibly at the top of each page of your essay.
A. Please
describe a significant challenge or obstacle you have experienced in your life
and the impact it has had on you.
B. If you had the opportunity to bring any person —
past or present, fictional or nonfictional — to a place that is special to you
(your hometown or country, a favorite location, etc.), who would you bring and
why? Tell us what you would share with that person.
SHORT ANSWER QUESTIONS
Attach your typed answers for
each of the questions below. Please ensure your full name and School ID
appear legibly at the top of each page.
1. Please
describe yourself. How would others
describe you?
2. The scholars
meet regularly to determine service, social and cultural events. There are leadership opportunities available
as well. Explain how you would contribute
to the student organization.
3. Select
two extracurricular activities you participate in. Why do you participate?
4.
What is your philosophy on
service? Why is serving others important
to you?
5. Why
are you a good candidate to receive this award?
What will you do if you don’t receive this award?
6. What
do you hope to accomplish while at ____________?
APPLICATION
INFORMATION:
In addition to the application, a
sealed official copy of your high school transcript reflecting grades from the
first reporting period of your senior year and two signed letters of recommendation are required. One of the
recommenders must be a high school teacher.
Mail application/letters of
recommendation and updated transcript to:
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