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Thank you for your interest in the scholarship from the Missouri Council of Practical Nursing Educators. All fields must be completed or your application will not be considered. Your application will receive consideration without regard to race, sex, national origin, age or religion.
Date of Application ____________________________________________________
Name ________________________________________________________________________________________________________________________
Permanent Mailing Address _______________________________________________________________________________________________________
Cell Phone Number __________________________________________Home Phone Number __________________________________________________
Give the name, address and phone number of the Practical Nursing Program you are presently attending _____________________________________________________________________________________________________________________________
Financial Assistance:
Please indicate your budgetary needs. Please use additional pages if necessary.
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Please state any personal or extenuating circumstances that would assist in the evaluation of your scholarship application. Please use additional pages if necessary.
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I authorize the Missouri Council of Practical Nursing Educators Scholarship Committee to obtain any information related to my financial/educational records and release this information to those persons involved in the selection of the scholarship recipients.
Signature of Applicant _____________________________________ Date __________________________________________
Originated 11/26/08
Updated 10/13/09