MID-OHIO DISTRICT NURSES ASSOCIATION

APPLICATION FOR GENERIC NURSING STUDENT EDUCATION SCHOLARSHIPS

 Be sure you read and understand all procedures before submitting the application. Please TYPE application and attach additional pages as necessary. DO NOT SEND A RESUME OR CURRICULUM VITA. Completed applications must be returned to the District Office no later than December 5, 2008.

NAME: _____________________________________________________________________________

                                     (Last)              (First)            (Maiden/Middle)

ADDRESS: _________________________________________________________________________

                                    (Street)                                                             (City)               (State)  (Zip)

TELEPHONE NUMBER:___________________________EMAIL ADDRESS____________________

SOCIAL SECURITY #: ___________________________

EDUCATIONAL BACKGROUND: (List most recent first):

School:             ____________________________                _________________________

Address:           ____________________________                _________________________

                        ____________________________                _________________________

Degree:            ____________________________                _________________________

Dates:               ____________________________                _________________________

School: ____________________________                _________________________

Address:           ____________________________                _________________________

                        ____________________________                _________________________

Degree:            ____________________________                _________________________

Dates:               ____________________________                _________________________

CONTRIBUTIONS:

1. COMMUNITY/VOLUNTEER ACTIVITIES:

            (Include terms of office, years on committees, etc.)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

2. HONOR SOCIETIES/RECOGNITIONS:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

3. OTHER MEMBERSHIPS: (Include terms of office, years on committees, etc.)

______________________________________________________________________

______________________________________________________________________

EMPLOYMENT (List most recent first):

1) EMPLOYER: __________________________________________________________    

            ADDRESS:  _______________________________________________________

TITLE/POSITION: _________________________________________________           SUPERVISOR:_____________________________________________________  

DATES OF EMPLOYMENT: _________________________________________

FULL-TIME __________ IF NO, # HOURS PER WEEK:___________________

JOB RESPONSIBILITIES: ___________________________________________

__________________________________________________________________

__________________________________________________________________

2) EMPLOYER: __________________________________________________________    

            ADDRESS:  _______________________________________________________

TITLE/POSITION: _________________________________________________           SUPERVISOR:_____________________________________________________  

DATES OF EMPLOYMENT: _________________________________________

FULL-TIME __________ IF NO, # HOURS PER WEEK:___________________

JOB RESPONSIBILITIES: ___________________________________________

__________________________________________________________________

__________________________________________________________________

ACADEMIC INFORMATION:

DEGREE SOUGHT (Major & Specialty):_______________________________________

UNIVERSITY: ___________________________________________________________

ADDRESS: ______________________________________________________________

EXPECTED MONTH & YEAR OF GRADUATION: ____________________________

REASON FOR SELECTING THIS PROGRAM: ________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

COURSE WORK REMAINING AT TIME OF SCHOLARSHIP APPLICATION:

CREDIT HOURS REMAINING: ______________

Your school operates on (circle one): SEMESTER,  TRIMESTER,  QUARTER

ARE YOU AWARE OF ANY PERSONAL SITUATIONS THAT WOULD PREVENT YOU FROM COMPLETING THE EDUCATION PROGRAM?

_____ NO

_____ YES, PLEASE SPECIFY: _____________________________________________

________________________________________________________________________

IN ADDITION...PLEASE ATTACH THE FOLLOWING:

1. Proof of acceptance to the educational program.

2. A tentative plan of course work to complete your degree.

3. A page-long narrative explaining how this educational program will help you achieve your personal career goals and a paragraph describing how you envision impacting the nursing association in the future as an RN.        

_________________________________________      __________________________

                        (Signature)                                                                    (Date)

Mail your application and attachments to:

MID-OHIO DISTRICT NURSES ASSOCIATION

1520 Old Henderson Road, Suite 100

Columbus, Ohio 43220