PNWSGNA Bette Schulenberger Memorial Scholarship Fund

Application Form

Instructions for Application:

1. Complete the following application form (please print legibly!).
2. Send completed application to the current PNWSGNA Scholarship Chair (contact information located on www.pnwsgna.org).
3. Applications must be received by March 1^st.

Applicant Contact Info	Name: ­­­­­­­­­­­­­___________________________________________________________________ Credentials: _______________________________________________________________ Home Address: ____________________________________________________________ City: __________________________  State: ________  Zip Code: ___________________ Home Phone: ______________________________________________________________ E-Mail Address: ___________________________________________________________ Employer: ________________________________________________________________ Employer Address: __________________________________________________________ Work phone: _________________________ Work FAX: ___________________________ Name of immediate Supervisor: _______________________________________________ May we contact him/her for information if needed?   Yes         No How would you prefer that we contact you?               Work      Home
Membership Info	1.      SGNA Membership #: __________________________________ 2.      Are you a member of PNWSGNA?        Yes         No (Disqualified from scholarship) 3.      How long have you been a member of PNWSGNA? _____________________________
Application Questionnaire	4.      Are you applying for another scholarship to attend the upcoming SGNA National Conference?	Yes, in the amount of: _____________________	No
	5.      Have you received another scholarship to attend the upcoming SGNA National Conference?	Yes, in the amount of: _____________________	No
	6.      Are you receiving any funding from your employer to attend the upcoming SGNA National Conference?	Yes, in the amount of: _____________________	No
	7.      Have you ever attended the SGNA National Conference?	Yes	No
	8.      Are you applying for certification at the upcoming SGNA National Conference?	Yes	No
	9.      Have you received the Bette Schulenberger Memorial Scholarship in the past?	Yes, in the following years: _______________	No
	10.  Have you served on the PNWSGNA Board in the past 5 years?	Yes	No

Personal Statement	Please attach a brief Personal Statement that addresses the following points: Your involvement in your workplace; your GI interest; your community activities; any publications; participation in educational activities (coordinating, planning, teaching, etc.) Why you want to attend the conference (What are your goals for attending the conference?) How this event will help you in your work How you will share your experience with co-workers Any other special circumstances (including financial hardship) that might bear on this application, if applicable
Terms of Agreement	I understand that, if I receive a PNWSGNA Bette Schulenberger Memorial Scholarship, I am required to apply the funds received toward the registration expenses for the upcoming SGNA National conference Within 30 days following the course, I agree to: a) Submit a copy of my Certificate of Attendance to verify my attendance at the program; b) Submit documentation of my actual use of the scholarship funds; and c) Submit an article to be printed in the PNWSGNA newsletter, “The Lightsource.” I also agree to share information from this experience with my colleagues.  I attest that all information provided in this application is true and accurate to the best of my knowledge and that I have met eligibility criteria for this scholarship.   Signature: ______________________________________________  Date: __________________
Status (Board to Complete)	Approved on: ________________ (date)        Denied on: __________________ (date)    Letter of Approval / Denial sent to applicant 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 Scholarship Chairperson: ____________________________________________________