PNWSGNA Andy Gilmore Memorial Scholarship Fund

Nomination Form

Nominee Contact Info	Name: ________________________________________________________________ Workplace: ____________________________________________________________ E-mail address: _________________________ Work phone: ____________________
Applicant’s Contact Info	Name: ­­­­­­­­­­­­­__________________________________________________________________ Home Address: ___________________________________________________________ City: __________________________  State: ________  Zip Code: __________________ Home Phone: ____________________________________________________________ E-Mail Address: __________________________________________________________ Employer: _______________________________________________________________ Employer Address: ________________________________________________________ Work phone: _________________________ Work FAX: _________________________ How would you prefer that we contact you?               Work      Home   **SGNA Member since: ___________________________________________________
Instructions For Nomination	1.      Complete the application form, above (please print legibly!). 2.      Attach descriptive information concerning your applicant’s eligibility. 3.      Send completed application form (with attachment) to the current PNWSGNA Scholarship Chair (contact information located on www.pnwsgna.org).

PNWSGNA Andy Gilmore Memorial Scholarship Fund Recipient Agreement Form

Instructions:

1.    The Scholarship recipient reviews and signs the Terms of Agreement, below.

2.    The PNWSGNA Scholarship Chairperson will:

a.     Complete the “Status” section of this form (below)

b.    File this completed form with the PNWSGNA Andy Gilmore Memorial Scholarship records

c.     Update the PNWSGNA Andy Gilmore Memorial Scholarship Recipient Table

Terms of Agreement	I agree to apply the Andy Gilmore Memorial Scholarship funds that I receive towards my expenses for attending the upcoming SGNA National Course. Within 30 days following the opening day of the conference, I agree to: a) Submit a copy of my Certificate of Attendance to verify my attendance at the program to the PNWSGNA Scholarship Chair; b) Submit documentation of my actual use of the scholarship funds to the PNWSGNA Scholarship Chair; and c) Submit an article to be printed in the PNWSGNA newsletter, “The Lightsource” to the PNWSGNA Newsletter Editor. In addition, I agree to allow PNWSGNA to forward this article to Olympus. I understand that within 14 days of receipt of the above, the PNWSGNA Treasurer will draft a check in the amount of the Andy Gilmore Scholarship.   Recipient’s Signature: ________________________________________  Date: ____________   Print Name: _________________________________________________________________
Status (Board to Complete)	Scholarship Recipient approved by the PNWSGNA Board on: ________________ (date)
	Did scholarship recipient meet all the Terms of Agreement, above?	Yes     No
	Submitted copy of Certificate of Attendance within 30 days post course?	Yes     No
	Submitted documentation of use of funds within 30 days post course?	Yes     No
	Submitted newsletter article within 30 days post course?	Yes     No
	Comments:         Signature of Board Member: ___________________________________________Date: __________