Chi Eta Phi Sorority, Inc., Gamma Chi Chapter

A Professional Nursing Organization

Reference Form

Minority Nurse Scholarships

APPLICANT INFORMATION

Please complete this section and give this form to your supporting person.

Applicant’s Name: ______________________________________________________________

(First)                                           (MI)                                                     (Last)

Classification:             ____ junior          _____Senior

THE ABOVE NAMED INDIVIDUAL IS APPLYING FOR a scholarship from Gamma Chi Chapter, Chi Eta Phi Sorority, Incorporated.  Please response as requested below.

                                                                                                              Gamma Chi Scholarship Committee

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How long have you known the applicant? ________________.

Leadership:

Dependability:

Scholarship:

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Please write a brief narrative proving information relevant to the student’s application for this award.  Attach a free for or use the back of this page.  Send directly to: Chi Eta Phi Sorority, Inc., Gamma Chi Chapter.  Attn:  Scholarship Committee 3032 Briarcliff Road, Decatur, GA. 30329-2655.

Your Name __________________________________________ Relationship ______________________

Address __________________________________________________________ City/State________________________________

Home Phone________________________________ Cell_________________________________

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                               Signature                                                                      Date