* Required Field

Select One *

I am a current high school senior (including home school students) expected to graduate in spring 2014
I am currently taking classes at TJC
I am currently taking classes at another college
I have attended college but am not currently taking classes
I have never attended college but have a high school diploma or GED

General Applicant Information

U.S. Social Security Number: (no spaces or dashes)
TJC Student ID Number: (no spaces or dashes)
First Name: * MI: Last Name: *
Mailing Address: *
City: * State: *
Zip: *
County of Residence: *
Home Phone:
Cell Phone:
Email Address: *
Current Employer:
How Long:
Past Employer:
How Long:

Educational Information:

To be completed by all applicants:

Major / Area of Study or Intended Major: *
Do you intend to pursue a bachelor's degree? * Yes No
Have you been accepted into a Nursing or Health Science program? * Yes No Applied, awaiting response
If yes or applied selected, which program?
High School Attended: *
City: *
State: *
Year, or expected year, of high school graduation (ex. 2013): *

To be completed by high school seniors only:

Rank in senior class:
Senior class size:
ACT Composite Score:
SAT Read/Math Total:

To be completed by all applicants:

Have you attended any other college or university besides TJC? Yes No
If yes, please list name of colleges or university and dates attended:
Name/Location Attended From To

Note: A transcript MUST be on file with the TJC Registrar for any coursework completed at another college or university before your scholarship application will be reviewed.

Optional Information

Students may elect to complete any or all of the Optional Information section of this application; however, such information may be required to be considered for specific scholarships.

Date of Birth:
/ /
Citizenship Status:
U.S. Citizen
Permanent Resident
Marital Status:
Gender: Male Female
Ethnic Background:

Asian or Pacific Islander
American Indian or Alaskan Native
Black (Non-Hispanic)
White (Non-Hispanic)
1. Are you a first generation college student? Yes No
2. Did you participate in Girl Scouts of America? Yes No
3. Did you participate in Expanding Your Horizons (EYH)? Yes No
4. Did you or do you plan to participate in the East Texas Technology Students' Association spring contest? Yes No
5. Are/Were you a member of the Boys & Girls Club? Yes No
6. Are you a descendent of a WWI veteran? Yes No
7. Do you want to be considered for a scholarship that requires approximately 10 hours of community service per semester? Yes No
8. Are you or a blood relative a member of an optimist club? Yes No
9. Are you or a blood relative a member of Beta Sigma Phi? Yes No
10. Are/Were you a part of the Tyler Literacy Council's GED program? Yes No
11. Are/Were you a participant in Children's Village Home for Children? Yes No
12. Do you plan to become an English or English Literature teacher? Yes No
13. Please select if you plan to pursue one of the following occupations:
14. Do you plan to study chemical engineering? Yes No
15. Do you plan to study pre-law? Yes No
16. If offered at your high school, did you complete automotive technology dual-credit classes? Yes No
17. Have you ever received services from the Christian Women's Job Corp, the Literacy Council of Tyler, the Salvation Army, or the East Texas Crisis Center?
Yes No
18. Are you an employee or the dependent of an employee of Vesuvius USA, Inc.? Yes No
(If yes, please list name and relationship)
19. Are you an employee or the dependent of an employee of Brookshire's or FRESH? Yes No
(If yes, please list name and relationship)
20. Are either of your parents employed by an organization that has a religious affiliation? Yes No
(If yes, please list relationship and employer)
21. Were your parents or grandparents previously an employee of the Goodyear Tyler Plant? Yes No

If yes, please list full name(s) of former employee and dates:

Full Name Employed From To

22. Do you have a disability?

If so, please explain:

23. Are your parents or grandparents Tyler Junior College Alumni? Yes No

If yes, what are their name(s) & dates of attendance:

Name Attended From To
24. Are you related by kinship or marriage to any employee or board member of Tyler Junior College? Yes No

If yes, what are their name(s) & relationship(s) to you:

Name Relationship
Extra-Curricular Activities (1350 character limit)

This section is for current high school seniors only. List 7 or fewer extra- curricular activities including participation dates. Choose those activities that demonstrate overall ability and leadership.

Honors and Awards (1350 character limit)

This section is for current high school seniors only. List all academic awards as well as honors received since you were a freshman in high school (include dates and the organization that presented the award).

Volunteer or Community Service (1350 character limit)

List 7 or fewer (include estimated hours of participation, dates and type of activity). Select one activity and briefly describe its impact on your life. *

Short Answer Questions

Please answer the following questions as thoroughly as possible. Your answers should be concise but provide enough detailed information for committee review.

Use the space below to discuss your educational and career goals. Please be thorough including things such as the highest level of education you plan to pursue as well as the profession you hope to be employed in one day. (1350 character limit) *

Describe your most significant challenge or accomplishment and explain its value to your life today. (1350 character limit) *

State any personal or family circumstances affecting your need for financial assistance to attend college. (1350 character limit) *

Honors Program/Presidential Honors Scholarship

Please select one of the statements below *
I would like to apply for the Presidential Honors Scholarship and for admission to the Honors Program. (HS seniors only)
I have already received an official award letter from TJC for the Presidential Honors Scholarship and would like to accept the scholarship and be admitted to the Honors Program. (HS seniors only)
I would like to apply ONLY to the Honors Program.
I am not interested in the Honors Program.


To Be Signed by All Applicants *

I affirm that the information which I have provided on this application form and any additional material that I submit related to the scholarship process is complete, accurate, and true to the best of my knowledge. Pursuant to the Family Educational Rights and Privacy Act of 1974, as amended (FERPA), I hereby authorize Tyler Junior College to release the scholarship application information provided by me, as well as other official and unofficial Tyler Junior College information regarding my academic progress and status, to the scholarship donors for the purpose of providing the donors with information concerning my eligibility as a scholarship recipient. I also understand that furnishing false information may result in revocation of my scholarship or may result in disciplinary action pursuant to the Tyler Junior College Code of Student Conduct.

I have read, understand and agree to the Certification above.