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Grants, Programs and Scholarships Application (The Chickasaw Nation)

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Page 1 of 3 Form no. 04629 CS-EDU Rev. 9/2020
Grants, Programs and
Scholarships Application
The Chickasaw Nation is pleased to offer its students funding assistance for college. The
following is a list of programs, grants and scholarships that you may be considered eligible to
receive. Please read the description of each, and place a check in the box next to the
funding source for which you wish to be considered. You are encouraged to select all
areas in which you qualify. After completing this page, the attached application and provide us
with the required documentation, your application will be reviewed for consideration of funding.
All programs, grants and scholarships offered by the Chickasaw Nation are for Chickasaw citizens only. Full-time Chickasaw Nation
employees will complete Form 04629E to apply for programs, grants and scholarships (this excludes CEA employees). School-to-
Work Program employees will complete Form 04629S. No student will be considered for funding who does not have a Chickasaw
Nation citizenship card or citizenship confirmation. Applications and documentation can no longer be submitted by fax, however you
may apply online and upload your documents. All programs, grants and scholarships applications and documentation will be delivered
via postmarked U.S. Mail, email or in person to the education services office by established deadlines – spring semester – Feb. 15
th
/
summer semester – July 1
st
/ fall semester – Sept. 15
th
. For quarter system students the deadline will be one month from the start date
of the term. By signing the application, you declare that you have read and understand the Chickasaw Nation Higher Education Student
Handbook concerning the Chickasaw Nation Higher Education programs as they relate to funding students who are attending college. You
may find the handbook at www.chickasaw.net/highered

PROGRAMS, GRANTS AND SCHOLARSHIPS
Please check ONLY the Items for which you wish to be considered
Higher Education Grant Chikasha Holitoplichi – Graduation Stole Program
*Attend three credit hours or more each semester *Will earn an associate’s degree or higher at an accredited
*Maintain a GPA of 2.0 or higher college or university
*Eligibility is limited to one award per student per degree
Fee Assistance Grant
*Attend three credit hours or more each semester
*Maintain a GPA of 2.0 or higher Concurrent Enrollment
High school juniors and seniors who are eligible for
concurrent enrollment and enrolled at an accredited
General Scholarship Program college/university in no less than three credit hours.
*Attend three credit hours or more each semester If the student’s state of residence pays concurrent
*Maintain a GPA of 3.0 or higher tuition, higher education will pay costs for fees and books.
Full-time Chickasaw Nation employees are ineligible. Students will follow all the guidelines of the
higher education grants and submit the following:
Text Book Grant 1. Complete higher education grants and scholarship
*Attend three credit hours or more each semester in college. application.
*Maintain a GPA of 2.0 or higher 2. High school transcript.
*Part-time undergraduate, graduate or doctoral – up to $250 3. Copy of college class schedule.
per semester 4. If seeking textbook reimbursement – a receipt for textbooks
*Full-time undergraduate, graduate or doctoral – up to $500 with the vendor’s name and contact information that
per semester shows amount paid.
5. Detailed billing statement showing cost of fees and tuition
Grant Type - Reimbursement – Receipts required by: (please keep in mind that we will not fund over the normal
Spring semester – March 15
th
amount of regular funding).
Summer semester – July 1
st
Fall semester* – October 15
th
Gift card – Current award receipts due by
next semester deadline
*Students have six months from the load date to use all money
on the card (see Section V.G.1 of Student Handbook).
Required Fields
Applicant – please complete
Name: ________________________
Semester Applying for Funding:
Spring 20 ____ Summer 20 ____
Fall 20 ____ Intersession
Quarter
College Classification:
Freshman Graduate
Sophomore Doctorate
Junior Concurrent
Senior
Degree:
Associates Masters
Bachelors Doctorate
Bill Anoatubby
Governor
Education Division
300 Rosedale Road / Ada, OK 74820 / Phone: (580) 421-7711
Website: www.chickasaw.net/highered
Page 2 of 3 Form no. 04629 CS-EDU Rev. 9/2020
College Information
Bill Anoatubby
Governor
Grants Programs and Scholarships Application
DEADLINE is Feb. 15
th
for spring semester / July 1
st
for summer semester / Sept. 15
th
for fall semester.
Personal Information Student Checklist
First name: ________________________________
Middle name: ______________________________
Last name: ________________________________
Maiden name: _______________ Suffix: _______
Birth date: _________________
Gender: Male Female
Mailing address:
__________________________________________
Street City State ZIP
Physical address:
__________________________________________
Street City State ZIP
Cell phone: (____) _____________________________
Text alerts – standard message and data rates may apply
Home phone: (____) ____________________________
(if applicable)
Email address: (required field)
_____________________________________________
Application Type:
New (did not apply last semester) Concurrent
Renewal (applied last semester)
Semester Applying for Funding:
(Please check only one)
Spring 20____ Summer 20____ Fall 20____
Intersession Quarter

Student Checklist:
Documentation Submitted:
Programs, Grants and Scholarships Application
Current college class schedule
Student Authorization for Disclosure of Information in
Education Records (beginning freshmen or new
applicants or renewals if not on file) – Page 4
Official college transcript
(if you have college credit hours)
High school transcript
GED/HSE scores (if applicable)
ACT/SAT scores if you are home schooled
College attending: _______________________________________________________________ Field of study: _____________________________________________________________
Financial aid / scholarship address: ___________________________________________________________________________________________________________________________
City: ____________________________ State: __________ ZIP: __________ College classification: Freshman Sophomore Junior Senior
Student ID no: __________________________ Expected graduation date: ________________ Graduate Doctorate
Contractual agreement – I declare that I will use any funds I receive from the Chickasaw Nation Higher Education Program solely for expenses connected with attending
____________________________________________________. I also certify that the above information is true and correct to the best of my knowledge. I grant consent to release this
information to the necessary agencies to complete my financial aid package. Disclaimer: Any dispute over student eligibility will be decided by the Chickasaw Nation Education Services
Program. The decision of Chickasaw Nation Education Services will be final.
Student’s signature Date
Student Contract – By signing the application, I declare that I have read and do understand the Chickasaw
Nation Higher Education Student Handbook concerning the Chickasaw Nation Higher Education programs
as they are related to funding students who are attending college. I also understand that these policies are
not all encompassing and may be changed as needed to assist Chickasaw students in a better way. The
Chickasaw Nation Higher Education Student Handbook can be found at: www.chickasaw.net/highered
Page 3 of 3 Form no. 04629 CS-EDU Rev. 9/2020
Student Authorization for Disclosure of Information
In Education Records
Pursuant to Family Educational Rights and Privacy Act of 1974, as amended
Instructions:
To authorize the Chickasaw Nation Higher Education Program to obtain your educational information and to authorize the Chickasaw
Nation Higher Education Program to release your educational information to individuals or the college/university you are attending
1. Fill out all appropriate fields on this form; and
2. Hand-deliver or mail the form to the address to the right.
3. Note: Forms will not be accepted without a signature.
First name:
Middle name:
Last name:
Suffix:
Birth date:
Please enter the name of the organization(s) or individual(s) to whom the authorization is given or revoked. You may enter more than one
name. Enter only ONE name per space.
Organization(s) authorized
given revoked
given revoked
given revoked
given revoked
Individual(s) authorized
Birth date
given revoked
given revoked
given revoked
given revoked
Authorization:
I hereby authorize the to disclose my educational record(s) to the above-mentioned organization(s) or individual(s)
and also authorize to disclose or obtain my educational record(s) to/from
Student’s signature Date
Parent/legal guardian signature (if applicable) Date
To enhance security measures, students now have the option to generate a PIN for their student files. Anyone seeking information regarding your student file will be required to verify the PIN before
information will be released. This can be done by going to www.chickasaw.net/highered and clicking on “fill form out online.” By initialing the line below you are refusing this service and allowing
organizations/individuals to retrieve information regarding your file based solely on this form.
_____
Student’s Initials
The vision of the education services division is to provide services that encourage and support academic and professional development of Chickasaw students.
Education Services
Higher Education Program
RETURN COMPLETED FORM TO:
The Chickasaw Nation
Higher Education Program
300 Rosedale Road
Ada, Oklahoma 74820
Bill Anoatubby
Governor
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Completed 31 January 2021

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