The New Jersey State Association of Occupational Health Nurses, Inc.

NJSAOHN SCHOLARSHIP APPLICATION
2012 Moore Medical Supply Scholarship

Sponsored by Moore Medical Supply

Personal Information

*Full Name:
*Address:
*City:
*State:
*Zip Code:
*Chapter:
*AAOHN membership ID#:
*Home Phone:
Cell Phone:
*Email:

Employment Information

Current Employer:
Supervisor's Name:
Address:
City:
State:
Zip:
Shift:
Work Phone:
Work Email:

If not currently employed, please list recent work history:

Provide a brief narrative addressing the following:

Your contribution to occupational health at your work site and the impact that this scholarship will have on your practice.

Any additional comments to assist in determining eligibility for the scholarship:

To evaluate the effectiveness of the scholarship program, please submit confirmation of attendance, CEU receipt or certification to the scholarship committee.

I understand that if I receive the award it will be used exclusively in pursuing the above stated goals and any monies not used will be returned to the organization.