The Chacko and Lize Simon Scholarship  Fund (B.C.)

Application Form


    Full Name of Applicant________________________________________________Male___ or Female___

    Birth Date__________________________S.I.N.______________________e-mail________________________

    Full Postal Address__________________________________________________Phone No._______________

    Names of Parents___________________________________________________________________________

    Occupation of Parents____________________ Number of Parents' Dependents___________________________

    Total Annual Family Income________________________(enclose copy of last year's income tax assessment)

    School____________________________________________________________________________________

    Name of Principal, Councilor or Teacher___________________________________________________________

    Academic Standing___________________________(please attach  offiial trasnscript of grades for last three years)

    Extracurricular Activities (Sports, Clubs, Hobbies, Community Service)____________________________________

    __________________________________________________________________________________________

    Part Time Work Experience____________________________________________________________________

    Career Goals________________________________________________________________________________

    College Program___________________________________________ Length of Course____________________

    Amount Needed for Course Fees Each Year______________  Date Fees Required__________________________

    Are You Applying for Other Scholarships?_________________________________________________________

    __________________________________________________________________________________________

    PLEASE ATTACH THE FOLLOWING SUPPORTING DOCUMENTATION:

       * A letter from the applicant giving a biographical profile and his/her aspirations
       * Transcript of marks for the last three years of education
       * Letter of recommendation from a teacher or counsellor
       * Letter of reference from respected member of community (priest, doctor, school principal, employer, etc.)
       * Proof of financial need supported by income tax statement if possible

Forward  Your Application to:

Dr. P.C. Simon, President,
The Chacko and Lize Simon Scholarship Fund
2550 Point Grey Road,
Vancouver, B.C.,
Canada, V6K 1A3  
Phone: (604)736-7035

e-mail:

Applications Must be Received Before March 1 of Each Year