Graduate Nursing Scholarship Application Form I am applying for the following scholarships (check all that apply): Trust Graduate Nursing ARNNL 50th Anniversary Marcella Linehan Bay St. George Chapter A. Personal Information (Please Print) Name: Address: (street) Phone: (H) (W) (city/town) E-Mail: (prov) (postal code) ARNNL Registration Number: Social Insurance Number: (required for income tax purposes) How long have you resided in NL? years Do you currently reside in the Bay St. George area of NL? Yes No If yes, how long have you resided in the area? years Are you a graduate of the General Hospital School of Nursing, St. John’s, NL? Yes No If yes, when did you graduate? Have you previously received a Trust scholarship or bursary? Yes No If yes, please specify award(s) and date(s): B. School Information School: Program: Masters Doctorate Current Enrollment Status: Full Time Number of Courses: Completed: Part Time To be Completed: Currently Enrolled: Program year: 1 2 3 4+ Please provide the following information about your Dissertation or Clinical Project: Click here if N/A Phase: Proposal Data Collection Report Writing Other (specify): Estimated timeframe for completion: Title: PLEASE DO NOT STAPLE THE APPLICATION FORM OR SUPPORTING DOCUMENTATION APPLICATIONS ARE NOT ACCEPTED BY FAX C. Education List any post-basic education you have completed. Include degree programs (e.g., BN, MN) and relevant diploma or certificate programs (e.g., specialty certification). List the most recent first. Institution Diploma/Certificate/Degree Date D. Work Experience Please list your work experience, starting with the most recent. Employer Position Area/Specialty Date E. Extracurricular Activities Are you a member of a Nursing Special Interest Group? Yes No If yes, please specify: Special Interest Group Position Held (if any) Date Please list any work related activities in which you participate (e.g., committees, councils, etc.) Association/Organization Position Held (if any) Date Please list any community or volunteer groups or activities in which you participate. Association/Organization Position Held (if any) Date F. Achievements Please list any awards or honours you have achieved. For academic achievements, please include post-secondary level ONLY. Award/Honour Date G. Financial Assistance List any financial assistance and amount received for this academic year (e.g., scholarships, bursaries, grants) Type of Assistance Funding Source Amount H. Personal Statement Please provide a brief statement about your professional career plans that addresses your commitment to nursing (maximum 500 words) I. Reference Please supply one reference from a nursing faculty member from your current program who can indicate your academic ability and potential for contributions to nursing. A reference from your thesis/clinical project supervisor is preferred. If you are unable to provide a reference from a faculty member in your current program, you may use someone from your previous academic program (e.g., BN or MN). References from nursing colleagues will not be accepted. The reference form is available on the Trust website. You must provide the referee with your ARNNL Registration Number. A reference has been requested from: Name Position Organization J. Supporting Documentation Please see the Application and Supporting Documentation Requirements document for a list of documents that must be received by the application deadline in order for your application to be considered complete. K. Declaration By submitting this application, I acknowledge the following: I have read the scholarship/bursary eligibility criteria and the entire application form. I have provided information that, to the best of my knowledge, is complete, true and accurate. I understand that failure to provide complete, true and accurate information may prevent my receiving a scholarship/bursary now or in the future. If any of the information provided should change, I understand that it is my responsibility to notify the Trust of the changes. I authorize the Trust to use my name for publicity purposes regarding the recipients. Signature Date Late or incomplete applications will not be accepted.
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