PTK Direct Admission Scholarship Form

Student Information

First Name*

Do you have a preferred first name?

Yes

Preferred Name

Last Name*

Birthdate*

Gender*

Email Address*

Mobile Phone*

Would you like to receive text messages?*

Mailing Address*

Country

Street

City

Region

Postal Code

Citizenship*

Ethnicity*

Academic Information

Entry Term*

Academic Interest*

DeleteCollege / University _ID_
Please begin typing the name of the college/university and select from the drop down below. College Transcript Please upload a copy of your unofficial college transcript. Prior to enrollment, we will require official transcripts from all colleges attended.

Add College / University

High School *

Application Information

Please upload your Phi Theta Kappa Certificate*

Housing Preference*

Have you ever been adjudicated guilty or convicted of a misdemeanor or felony?
Note that you are not required to answer "yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise required by law or ordered by a court to be kept confidential*

Yes

Please provide the details of your criminal conviction or adjudication and reflect on what you learned from the experience.*

Signature*