BTL | Scholarship Application Form 1

Scholarship Application Form

Scholarships awarded are based on financial need and academic merit in addition to the following minimum requirements:

Applicants MUST be a Belizean or a child of a Belizean and have been residing in Belize for at least three (3) consecutive years.

Applicants whose parents or guardians’ combined gross annual income is $20,000.00 or more will

not be eligible for a scholarship. Applicants MUST be between the ages of eleven (11) and fourteen (14).

Applicant MUST be entering High School for the first time.

The applicant must be successful in the Primary School Examination (PSE) for the year of their

graduation from primary school. All of the following documents MUST be submitted along with this application form for consideration by the BTL Scholarship Committee. Failure to provide one or more document will result in immediate disqualification.

A copy of the applicant’s birth certificate Parents/Guardians Tax TD4 Supplementary slips OR official income statement letter from the

Income Tax Department in your district OR letter from employer (necessary for both working

parents/guardians where applicable) A copy of the applicant’s PSE results (when published) A copy of the applicant’s yearly report cards for Standard 4, 5 and 6

Completed forms MUST be signed by applicant’s primary school principal and submitted on or before June 16 of this year to:

Public Relations Department Belize Telemedia Limited

Regent Street P. O. Box 603

Belize City, Belize

BTL | Scholarship Application Form 2

Note: Documents provided will be property of BTL Keep a copy of all documents submitted All applicants are considered without regard to sex, race, creed or color Failure to provide all information accurately may result in immediate disqualification. Responses must be clearly written on lines provided.

Candidate’s Information Surname: __________________________ First Name: ___________________________________ Middle Name: ______________________ Sex (male/female): _____________________________ Date of Birth: _______________________ Place of Birth: _________________________________

(m/d/y) Residing in Belize since: ____________________

Address: _____________________________________________________________________________ Telephone #(s): ________________________________________________________________________

(If no telephone number, kindly provide other contact number)

Father’s Information Father’s full Name: _____________________________________________________________________ Father’s Place of Birth: ______________________________ Living/Deceased: __________________ Father’s Address: ______________________________________________________________________

Telephone #(s): ______________________ Father’s Occupation: ____________________________

Father’s Annual Income: ________________________________________________________________ Specify amount & attach TD4, income tax or employer letter

Father’s Employer: _____________________________________________________________________

(Name)

_____________________________________________________________________ (Business Address)

Mother’s Information Mother’s full Name: ____________________________________________________________________ Mother’s Place of Birth: __________________________ Living/Deceased: __________________

Mother’s Address: _____________________________________________________________________

Telephone #(S): _________________________ Mother’s Occupation: _________________________

BTL | Scholarship Application Form 3

Mother’s Annual Income: _______________________________________________________________ Specify amount & attach TD4, income tax or employer letter

Mother’s Employer: ____________________________________________________________________

(Name) ___________________________________________________________________

(Business Address)

Guardian Responsible (if not parent/s): Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Occupation: ___________________________________________________________________________ Telephone #(s): ____________________________________________________________________ Business Address: ______________________________________________________________________ Annual Income: _______________________________________________________________________ Specify amount & attach TD4, income tax or employer letter

Guardian’s Employer: ___________________________________________________________________ Number of children dependent on parents/guardian and their ages (Other than applicant): Boys: ___________ Ages: _____________ Girls: _____________ Ages: _______________ Number of children presently attending high school: _______ Current Form(s): ____________________ Number of children presently attending a tertiary level institution: 6th Form: ____ UB: ____ Other: _____ Number of children currently on any scholarship program: _____________ Have any children in your family received a BTL scholarship? : Yes / No If yes, list name of child or children: _______________________________________________________

Certification of Parent or Guardian: List below in order of preference, the secondary schools of the applicant’s choice. At least three (3) schools should be listed. Kindly place a check mark () beside school that has accepted applicant 1. ___________________________________ 3. ____________________________________ 2. ___________________________________ 4. ____________________________________

BTL | Scholarship Application Form 4

I certify that all information given on this form is accurate and correctly stated. I fully understand the conditions under which BTL’s scholarship award is made. I accept these requirements and am prepared to abide faithfully by them. The schools listed are the schools of my child’s choice (in order of preference), which he/she would like to attend. __________________________________ ___________________________________ Parent’s / Guardian’s Signature Date Certification of Principal: I hereby certify that the applicant __________________________________________________ of

(Name of Applicant)

_____________________________________ in the ____________________________________ (Name of School) (District)

received a PSE percent of ______________ and meets the age requirements of BTL’s scholarship award. The date of birth of the applicant given on this form is the same as that on the birth certificate and is, in my opinion, industrious, of good character, and deserving of this scholarship award to a secondary school. _________________________________ ___________________________ Principal’s Signature Date Be sure to review your application for accuracy and completeness. If you feel there are any special circumstances concerning your application that you would like the committee to consider, please attach a written explanation. _____________________________________________________________________________________

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