Austin Area AORN

Scholarship Application

Name:________________________________________________

Home Address:_________________________________________

            ________________________________________________

Home Phone:_________________  Work Phone: _______________

Employer:______________________________________________

Address:_______________________________________________

                ______________________________________________

College/University Information

For attendance at:

School of _______________________Admission Date:____________

Address:_________________________________________________

________________________________________________________

Name of Dean:_____________________________________________

Degree pursuit:    _____Baccalaurate  (Must be in Nursing)

                           _____Masters (Must be in Nursing)

                            _____Doctoral

Anticipated number of credit hours per course period: ________

Number of credit hours completed to date: ________

Estimated completion date for degree: ________

Does you school devide the academic year into quarters, semesters, trimesters?  Please identify and explain how many per year:_______

____________________________________________________

____________________________________________________

Professional Information

Membership in professional organizations:  _____AORN   _____ANA

Membership number: __________   Number of years in AORN: _____

Personal statement in support of application.  Include any experiences which have influenced your decision to pursue advanced education and a statement of your Professional and educational goals.  Attach to this form or write below:

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

_____My grade report is included with this application.

_____My course registration form is included with this application.

Signature: _____________________________ Date:_________________

Completion of the application form does not guarantee a scholarship award.