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Mid-Ohio District Nurses Association
APPLICATION FOR ACADEMIC NURSING 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)
YEARS AS ANA MEMBER: ___________
SOCIAL SECURITY #: ____________________________
Member Expiration/Renewal Date:
________________________________________________________
List Professional Registrations
or Licenses Held (Specify State and #)
___________________________________________________________________________________
___________________________________________________________________________________
List Certification and Certifying
Authority and/or Organization:
____________________________________________________________________________________
____________________________________________________________________________________
EDUCATIONAL BACKGROUND BEYOND
HIGH SCHOOL (List most recent first):
School:
________________________________
______________________________
Address:
________________________________
______________________________
________________________________
______________________________
Degree:
________________________________
______________________________
Dates:
________________________________
______________________________
School:
________________________________
______________________________
Address:
________________________________
______________________________
________________________________
______________________________
Degree:
________________________________
______________________________
Dates:
________________________________
______________________________
ACADEMIC SCHOLARSHIP
APPLICATION P.2
PROFESSIONAL
CONTRIBUTIONS:
1. ANA/ONA/MOD
ACTIVITIES:
(Include terms of office, years on committees, etc.)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. HONOR SOCIETIES/RECOGNITIONS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. OTHER
PROFESSIONAL ASSOCIATIONS: (Include terms of office, years on committees,
etc.)
____________________________________________________________________________________
____________________________________________________________________________________
4. COMMUNITY/VOLUNTEER
ACTIVITIES: ______________________________________________
______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
5. RESEARCH:
_______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
6. PRESENTATIONS:
_________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
7. PUBLICATIONS:
___________________________________________________________________
____________________________________________________________________________________
ACADEMIC SCHOLARSHIP APPLICATION P.3
PROFESSIONAL NURSING 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:
______________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________
3) EMPLOYER:
_____________________________________________________________________________
ADDRESS:
__________________________________________________________________________
TITLE/POSITION:
_____________________________________________________________________
SUPERVISOR:________________________________________________________________________
DATES OF EMPLOYMENT:
____________________________________________________________
FULL-TIME __________ IF NO, # HOURS PER
WEEK:_______________________________________
JOB RESPONSIBILITIES:
_______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
ACADEMIC SCHOLARSHIP
APPLICATION P.4
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 OR proof showing application has
been received and is being
processed by
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.
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________________________________________________
________________________________
-
(Signature)
(Date)
-
Mail your application and attachments to:
-
MID-OHIO DISTRICT NURSES ASSOCIATION
1520 Old Henderson Road,
Suite 100
Columbus, Ohio 43220
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