Scholarship Application
For students currently enrolled in a Practical Nursing Program 2011-2012
The application needs to be filled out completely and returned to the address on the application by March 3, 2012. Any applications received after that date will not be accepted. All applications are read and judged on information received. Copies may be made. Print in ink or type, please.
Full Name ___________________________________________________________
Address _____________________________________________________________
Nursing School ________________________________________________________
Graduation Date ____________________________________________________ Current GPA ________________
Annual household income, please include all sources ________________________________________________________
Social Security __________ Child Support ___________ Wages ______________ AFDC ____________ Other ___________
Number of Dependents ______________ Marital Status ______________ Tuition Cost _______________
In no less than 50 words please indicate why you should be awarded this scholarship.
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Employment History:
1. ________________________________________ 4. ________________________________________
2. ________________________________________ 5. ________________________________________
3. ________________________________________ 6. ________________________________________
In no less than 50 words please indicate what you feel your ongoing contribution to the field of nursing will be upon graduation.
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Application Signature _________________________ Date ____________________
Faculty Comments
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Program Coorinator's Signature ________________________
Missouri State Association of Licensed Practical Nurses, Inc.
573-636-5659 or 1-800-283-1984
e-mail: mosalpn@centurylink.net
MoSALPN
PO Box 105542
Jefferson City, MO 65110
Fax 573-636-3732
www.mosalpn.org