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Chi Eta Phi Sorority, Inc., Gamma Chi Chapter
A Professional Nursing Organization
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APPLICATION FOR
BELLAMY, ROWSER, BINNS, CHI FELLOWS AWARD
Minority Student Nurse Scholarship Application
MOTTO: SERVICE FOR HUMANITY
Eligibility Criteria: (Check One)
___African American ___American Indian ___ African (Naturalized) ___Hispanic ___Asian/Pacific Islander
1. APPLICANT
A. Name SS#
(First) (Last) (MI)
B. Address
City State Zip .
Home Phone . Work . Cell
1. Do you live on campus? Yes. No If yes, Name of Dorm.
2. If no, with whom do you live? ..
C. Date of Birth Place of Birth .
D. Check one: Single .Married .Divorced ..Widowed ..Separated
E. Are you a citizen of the United States? .Yes .No
F. If no, are you a permanent resident of the United States? . Yes .No
Please describe circumstances ..
..
..
Church Affiliation .
II. CHARACTER REFERENCES (Give names and addresses of two persons, not your relatives. Give them the enclosed
Reference Form with instructions to submit as noted on the form.)
A . .
(Name) (Address) (Relationship)
B . ..
(Name) (Address) (Relationship)
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III: FAMILY INFORMATION
A. Father .... .
Name Address Occupation
B. Mother
Name Address Occupation
C. Spouse .
Name Address Occupation
D. Number of siblings dependent on parents: ( ) Number of children dependent on you/spouse: ( )
IV. EDUCATION
A. High School ..
Address
High School Scholastic Average
Name and address of the college in which you are enrolled and or attended: ..
.
B. Name of Address Year (s) of Degree/
College/University Attendance Diploma
..
C. Current Educational Status:
1. .............................................................................................................
Classification: (Freshman, Sophomore, Junior, Senior.)
2. In what area of nursing are you most interested? .
.
V. EMPLOYMENT STATUS
A. Are you presently employed? Yes. No. If yes: Full Time Part Time
B. Where? (List Address) .
Work Phone: ..
C. Type of Work/Job Title.
D. If you are a licensed nurse, in what state (s) are you currently registered? State ..Reg. # .
State .. Reg. # State . Reg. #
VI. EXTRA-CURRICULAR ACTIVITIES
A: List the Clubs and /or Organizations in which you take an active part.
B. List Honorary Societies in which you belong. .
C. List office(s) held in any Clubs and or Organizations.
.
D. List all awards, Honors or Citations received.
E. List any Sorority to which you belong.
.
.
VII. FINANCIAL STATUS
A. Are you currently receiving financial assistance? . Yes No
B. If yes, please complete.
Name of Grant/Loan Name of Scholarship
1. 1. .
2. 2. .
3. . 3. .
C. If you are awarded a scholarship from Gamma Chi, for what purpose will you use it? .
.
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D. Attachι any pertinent information that would be helpful in assessing your financial need for this scholarship.
______________________________________________________ ___________________________________
Signature of applicant Month/ Date/ Year
APPLICANT MUST ENSURE THE FOLLOWING:
· Submit the most recent transcript directly from the registrars office to the Committee at the stated address.
· Provide financial data from respective College/University or School of Nursing.
· Reference information must be mailed directly from provider to the Committee at the stated address.
· Photograph of Applicant (most recent).
· Letter from the applicant (Biography or Why I want To Be A Nurse).
· All information and Application reaches the Committee by Deadline of March 18, 2008.
· Address: Chi Eta Phi Sorority, Incorporated, Gamma Chi Chapter GNA Headquarters
3032 Briarcliff Road, Atlanta, Ga. 30329-2655