Chadron State College
Phi Theta Kappa Scholarship Application
Minimum requirements include an Associates Degree prior to attendance at CSC, proof of PTK membership, a 3.50 cumulative GPA
on a 4.0 scale from all colleges attended and enroll full-time at CSC. Complete and return this form to the Chadron State College,
Financial Aid Ofce, 1000 Main Street, Chadron, NE 69337 postmarked by March 1. To be considered for scholarships you
must apply to CSC at csc.edu/apply/now. Please print clearly or type.
I plan to transfer to CSC: Fall 20_____ Spring 20_____ On-Campus_____ Distance Education (On-line)_____.
Name: (Last, First, MI) _______________________________________ Date of Birth: (mm/dd/yyyy)__________
Permanent Address: _______________________________________ Telephone: ( ) _______________
City: ___________________________________ County: ___________ State: ______ ZIP: _____________
College Presently Attending: __________________________________ High School Attended: __________
Area of study ___________________________ Major/Endorsement _______________________________
NU ID: ____________________ Apply to CSC to receive a NU ID.
Most Current College – (Must be completed by Registrar)
Cumulative GPA ________________ Anticipated graduation date _______________
Cumulative Hrs. Completed ________________ Degree Type _______________
______________________________________
Signature of Registrar
I certify the above named student is an active member of Phi Theta Kappa at _________________________________
(Name of institution)
______________________________________
Signature of PTK Sponsor/Advisor
Please check all the following that apply
1. Currently live on a ranch or farm 10. Successfully completed the PPST
2. Descendent of a Chadron Prep Alum 11. Five years of 4-H plus 5 years of Home Economic 4-H projects
3. Attended rural Dawes County grade school 12. Pursuing a career as a kindergarten teacher
4. Nontraditional Student 13. Member of Phi Beta Lambda at least 1 year
5. Attended Chadron Kenwood Grade School 14. Eagle Newspaper staff member
6. Dependent of NE farmer/rancher or dependent of their employee 15. Plan to student teach in upcoming academic year
7. Involved in 2 college activities with 1 related to eld of study 16. Member or willing to become a member of Nebraska
8. Member of CSC Campus Historical Forum Association for Health, Physical Education, Recreation and Dance
9. Parents or Grandparents are CSC Alums
Based on your family’s adjusted gross income from the most recent tax year, please mark the appropriate income. Financial
aid need-based scholarships are awarded based on the income information below. Failure to accurately report the income
information may nullify the need-based scholarship award.
_______ $0 - $25,000 _______ $25,001 - $50,000 _______ Above $50,000
Attach the following:
(Your application will not be considered without all the following items.)
• Copy of ALL college transcripts • List all colleges attended
I certify the above information is correct to the best of my knowledge. I understand inaccurate information I have provided
may void any scholarships received. Applications with missing information will not be considered until all information is
received. If information is received after the deadline, the application will be considered late.
_______________________________________________ __________________________
Signature of Applicant (Must Be Signed) Date
If you have questions contact the Admissions Ofce: (308) 432-6263 or inquire@csc.edu
2012
