This application is to be completed printed and mailed to by mikeholy


									                                                                   2007-2008 CNF Scholarship Application


This application is to be completed on a computer. The signed original and copies as required (see section I)
                                            should be mailed to:

                                        Canadian Nurses Foundation
                                     50 Driveway, Ottawa, ON K2P 1E2
                                             Attention: Awards

                       The deadline for all applications is April 1, 2007, at 4 p.m. EST

                        Applications postmarked after this date will not be accepted.

         Handwritten applications will not be accepted unless there are extenuating circumstances,
                        which must be explained to CNF before March 21, 2007.

        Late, faxed, e-mailed, incomplete or illegible applications will not be accepted or considered.


What credential will you be earning?

• Full-time    Length of total program:
• Part-time    Part-time students must be taking more than one course per semester.
               Number of courses/credits to be taken each semester:
               Number of courses needed to complete the program:

Name:                                         • Ms • Miss • Mrs. • Mr.
Mailing Address:
E-mail Address:
Telephone Number(s):

   1. Name of university:
   2. Date of enrollment:

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                                                                       2007-2008 CNF Scholarship Application
     3. Expected date of graduation:
     4. Which year of study are you entering?
     Do you have a specific area of interest? If so please specify:
     Do you hold a current certification in your specialty? Yes •          No •


     1) Register with and submit a CIHR Common CV with attachments (https://www.ccv-, or a CV containing the following information:
          Academic Background
          Distinctions, awards, credentials
          Work experience
          Contributions (e.g., publications, abstracts, presentations, reports)
          Membership(s) and involvement in nursing organizations

     This section is Attachment “A”

 Please provide three completed Referee Appraisal Forms from individuals who can evaluate your job
 performance, educational aptitude, personal strengths, and leadership potential. At least one referee must be a
 faculty member, or a supervisor from your work setting. Please provide the following information about the

           Name/Position                             Work Address                      Telephone No. and E-mail

 The two page Referee Appraisal Form is Attachment “B”. Please save it as a separate document and email it
 to the three Referees listed above for completion. Your Referees will return the completed forms in sealed
 envelopes with a signature for you to enclose with your application form.


Please check the award(s) you are applying for (those that most closely match your specialty and/or experience).
Additional new awards may be introduced later for which all applicants will be considered according to their

• Dr. Helen K. Mussallem, C.C. Fellowship
Established by Dr. Musallem, whose many distinguished awards include the Florence Nightingale Medal
(International Red Cross), the award for Distinguished Achievement in Nursing Research and Scholarship
(Columbia University) and the Jeanne Mance Award (Canadian Nurses Association).
             Open to all eligible master level students.

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                                                                        2007-2008 CNF Scholarship Application
• Jill E. Schneuker/Baxter Corporation Fellowship in Nursing Sciences
Established by the Baxter Corporation, a recognized industry leader distributing, servicing, and manufacturing
more than 60,000 health-care and related products in Canada. In memory of Jill E. Schneuker, a former Baxter
Corporation employee.
             Open only to students in the Nursing Sciences program at the master level.

• Extendicare Scholarship in Gerontology
Established in 1989 by Extendicare, Canada’s largest provider of long term care and assisted living facilities,
including home health care and rehabilitative therapy services.
             Open to nurses, who intend to practice, teach or do research in gerontology/long term care.

                 In 100 words or less – I qualify for this award because:

• Hoffmann-LaRoche Hepatology Nursing Fellowship
Established by Hoffmann-LaRoche Limited, the world’s leading health-care company with a global perspective on
research, drug development and marketing; focusing on prevention, diagnosis, and treatment.
             Open to candidates pursuing a Nurse Practitioner or Advanced Nurse Practitioner Master of
                Nursing degree with an emphasis on Hepatitis C.

                 In 100 words or less – I qualify for this award because:

• The Aplastic Anemia and Myelodysplasia Nursing Grant
Established by the Aplastic Anemia and Myelodysplasia Association of Canada, who provide nation-wide support and
information for patients, families and medical professionals. The Association maintains the Unrelated Bone Marrow
Registry and raises funds for medical research.
             Open to nurses who will be focusing their research in the field of haematology or oncology.
                Preference is given to CANO members. Recipient must be willing to increase awareness of
                Aplastic Anemia and Myelodysplasia issues by presenting to colleagues and/or sitting on the Board
                of the Association.

                 In 100 words or less – I qualify for this award because:

•       Nova Scotia Nurses Master Scholarship
Established by the College of Registered Nurses of Nova Scotia in 2005.
             Open to nursing students from Nova Scotia who are members of the College of Registered Nurses
                of Nova Scotia.

                 In 100 words or less – I qualify for this award because:

• The Military Nurses of Canada Award founded by Col. Agnes Campbell Neill
Established by Colonel Agnes Campbell Neill, this award is provided by the Nursing Sisters’ Association of
Canada to assist outstanding registered nurses in furthering their studies.

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                                                                        2007-2008 CNF Scholarship Application
               Open to all eligible students at the master level. Preference is given to students who are a former
                Nursing Officer or have served in Her Majesty’s Forces or are a relative of a Nursing Officer/
                Nursing Sister or veteran.

                 In 100 words or less – I qualify for this award because:

• Nurses Association of New Brunswick Scholarship
Established in 1998 by the New Brunswick Nurses Foundation.
             Open to eligible students who are NANB members.

                 In 100 words or less – I qualify for this award because:

• Sanofi Pasteur Ltd. Scholarship in Public/Community Health
Established in 1990 by Sanofi Pasteur Ltd. the largest vaccine company in Canada. Its proud heritage of protecting
human life against infectious disease in Canada dates back almost 100 years – to the beginning of vaccine
production in this country.
             Open to all eligible students in a Master of nursing program.

                 In 100 words or less – I qualify for this award because:

I have read the entire application form. I have submitted complete and true information on this form and I understand
that failure to do so may prevent my receiving assistance now or in the future. If any of the information provided
should change, I understand that it is my responsibility to advise the Canadian Nurses Foundation immediately.

I understand that if I am selected to receive an award, I must provide the following documentation within 2 weeks of
               Proof of Canadian citizenship or permanent resident status.
               Proof of eligibility for specific awards if requested.

Signature of Applicant: _______________________________________                    Date: _____________________

  √    Section                                               Number of Copies
       A. Level of Study                                     Original Only
       B. Name and Contact Information                       Original Only
       C. Program of Study                                   Original Only
       D. Curriculum Vitae                                   Original + 3 copies (4 total)
       E. Personal Information                               Original Only
       F. References                                         Original Only
       G. Master Awards                                      Original Only
       H. Signatures and Declarations                        Original Only
       Attachment “A” Personal Information                   Original + 3 copies (4 total)
       Attachment “B” References                             3 Originals (1 from each reference) – sealed with

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                                                                 2007-2008 CNF Scholarship Application
    Transcripts                                        Original – sealed and initialed

Send the original application form and three copies of attachment “A” and three copies of your CV along
                        with your sealed (with signature across seal) referee letters to:

                                     Canadian Nurses Foundation
                                  50 Driveway, Ottawa ON K1P 1E2
                                          Attention: Awards

                              Please attach with paper clips, not staples.

            THE DEADLINE IS APRIL 1, 2007 AT 4:00 p.m., EASTERN STANDARD TIME.

                      Applicants will be advised of results by email by the end of June.
            It is your responsibility to provide CNF with any change to your email address.

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                                                                  2007-2008 CNF Scholarship Application
                                                                                             Attachment “A”

         The following information along with your transcript, references, and CV
                                 will be provided to the
                                Merit Review Committee

              Please make sure Attachment “A” pages are printed separately from the application.

Name of Applicant:

  1. Describe how you demonstrate professional and community leadership. (200 words or less)

  2. Describe your personal qualities that strengthen your performance as a nurse with advanced
     preparation. (200 words or less)

  3. Describe your future career plans. (200 words or less)

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                                                                     2007-2008 CNF Scholarship Application
                                                                                               Attachment “B”


                                              PLEASE TYPE




How long have you known the applicant?_____ years; in what capacity? ______________________________


Note to Referees:

Check the boxes below that most closely represent your assessment of the above applicant. Please provide
information, both pro and con, about the applicant in the space provided at the end of the form. Your overall
assessment of the applicant and his/her performance during the time you have known him/her is very important for
the review panel. We would ask that you give the sealed form (with your signature across the seal) directly to
the applicant to include with his/her Application Form.

Check the boxes below that most closely represent your assessment of the above applicant.
                        By reviewing this competency        Rarely Sometimes Often            Always     Unable
                        we consider:                       exhibits    exhibits    exhibits   exhibits     to
INDEPENDENCE            Pursuit of knowledge or taking
                        of action on own initiative,
                        seeking guidance when
KNOWLEDGE               Familiarity, awareness, or
SYNTHESIS               understanding gained through
                        experience or study
RESEARCH                Demonstrates potential for
APTITUDE                careful, systematic investigation
                        of a field of knowledge
FACILITATION            Ability to facilitate the
SKILLS                  integration of research-based
                        knowledge into practice

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                                                                      2007-2008 CNF Scholarship Application
                        By reviewing this competency       Rarely     Sometimes     Often      Always     Unable
                        we consider:                       exhibits    exhibits    exhibits    exhibits     to
ACCOUNTABILITY Ability to make own rational
                decisions and therefore be
ABILITY TO      Power to sway or affect based
INFLUENCE       on knowledge and ability
EVALUATION      Ability to examine and judge
SKILLS          carefully; appraise
PLANNING SKILLS Ability to design, program, or to
                work out a method beforehand
                for the accomplishment of an
COMMUNICATION Ability to work with, influence,
SKILLS          and impart knowledge to others
INVOLVEMENT     Extent of involvement in work
                or academic environment
INTEGRITY       Adherence to an ethical code;
                being of good character
VISION          Competence in discernment or
                perception; intelligent foresight
RELIABILITY &   Shows commitment to a course
DISSEMINATION   Commitment to dissemination
OF KNOWLEDGE    of knowledge via
                presentations/publications etc.
TEAM PLAYER     Extent of effort and cooperation
                extended to the collective
ORIGINALITY/    Imagination or ingenuity in
CREATIVITY      problem solving

Additional comments: Summary statement of applicant’s strengths and potential for making a significant
contribution to nursing profession. (200 words or less)

In what percentile would you rank this applicant compared to other students?

Upper 10%      •                              Upper 20%       •                               Upper 30%     •

Upper 40%      •                              Upper 50%       •                               Lower 50%     •

Referee’s Signature:

* By law, applicants have access to their own application files. The referee’s letters may be disclosed to the
applicant if a freedom of information request is made.

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                                                                   2007-2008 CNF Scholarship Application
Before you mail...

                 Have you...?

               Enclosed a $35.00 application fee by cheque or money order payable to the Canadian Nurses
                Foundation? Do NOT place the cheque loose in the application envelope. Fasten the cheque
                to the application with a paperclip. Please note that if your cheque is returned NSF, your name
                will automatically be removed from submission without notice.

               Arranged for official transcripts to be sent in sealed envelopes to CNF on or before the
                deadline date or have submitted them with your application? A student copy is not accepted.

               If you are entering the first year of the Master’s program enclose a letter of unconditional
                acceptance from the university/college you have chosen? If this letter is not available by the
                deadline, please advise in a cover letter. Letter of acceptance must be received by CNF no later
                than June 30.

               Completed every question in the application?

               Enclosed the original sealed and signed Referee Appraisal Forms (affixed with paperclips,
                not stapled)?

               Signed and dated your application and enclosed the original, plus copies as required (see
                section I) (affixed with paperclips, not stapled)?

               Ensured that all of the above documents are postmarked on or before
                April 1, 2007 at 4 p.m., Eastern Standard Time?

                 Do Not!

               Do not return this page with your application
               Do not request the University to send more than one copy of your transcript.

                                                                                                    Page 9

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