3420 THORNTON • AMARILLO, TEXAS 79109 • 806-353-3593

Scholarship Checklist • Completed Application with photo attached

• Copy of Transcript

• Completed Essays (250 - 400 words each)

• 1.5” X 2” Photo

Essay #1 As professionals in the dental field, we believe a healthy

smile can have a positive e�ect on the lives of our

patients. How do you feel about this statement? In other

words, how has your smile a�ected your life (in either a

positive or negative way)?

Essay #2 Although we believe that academics are very important,

we also believe that being involved in extracurricular and

community activities are equally important. In your life,

how have your activities outside the classroom influ-

enced you?

ALL APPLICATION MATERIALS MUST BE RECEIVED BY

MARCH 30

Harwell & CookOrthodontic Scholarship

PHOTO

1.5” X 2”

Drop o� or mail completed application to:“Scholarship”

3420 Thornton, Amarillo, TX 79109

SCHOOL NAME

Scholarship Application for Graduating SeniorsHarwell & Cook Orthodontics Scholarship

Please supply all the information requested below. A typed application is preferred. Black ink is

preferred. Attach a picture in the indicated block and a copy of your transcript. You may attach

additional pages, if needed.

NAME

ADDRESS ZIP PHONE EMAIL

AGE DATE OF BIRTH SS# US CITIZEN YES NO

Middle School Attended Elementary School

Parent/Guardian Name/Occupations/Places of Employment

Number of brothers/sisters Ages

How many family members, including yourself, will be in college next year?

List most notable community activities & school-related extra-curricular activities during grades 9 - 12 and check the appropriate grade level(s)

RANK IN CLASS

ACT Composite

Numeric Avg.

SAT Combined

ACTIVITIES 12 11 10 9 Level of Involvement(i.e. o�cer, member, etc.)

SPECIAL RECOGNITION, AWARDS OR HONORS 12 11 10 9 Group or Activity Sponsoringthe recognition

List special recognition, awards and honors received during grades 9 - 12 and check the appropriate grade level(s).

PLACE OF EMPLOYMENT 12 11 10 9 Job Description Supervisor

List and describe any work experience during grades 9 - 12 and check the appropriate grade level(s).

What college do you plan to attend?

Estimate college expenses for freshman year

Student’s Signature Date Parent’s Signature Date

Print Name Print Name