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Online Application Form |
PROVIDE A COPY OF THE LETTER OF ACCEPTANCE INTO THE ALLIED HEALTH PROGRAM.
* represents a required field |
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First Name |
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Last Name |
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Address 1 |
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Address 2 |
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City |
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State |
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Zip Code |
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Daytime Phone |
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E-mail Address |
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High School Attended |
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Year Graduated |
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County in which you reside (Limited to: Burt, Cuming, Dakota, Dixon, Thurston and Wayne counties) |
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College Attending |
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ACADEMIC PERFORMANCE & HEALTHCARE EXPERIENCE: |
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College grade point average |
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College transcript and copy of acceptance letter or notification of acceptance must be submitted If not submitted, please give explanation.
Submit copies to:
Merlin Brondum Memorial Scholarship
Attn: Kelly Kaup
PO Box 100
Pender, NE 68047 |
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Healthcare Experience |
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My career objective in three hundred words or less. Please relate your career objectives to the health needs of people living in rural areas. |
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College and community activities. (List activities, service clubs, work experience, etc.). |
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FINANCIAL NEED: Cost of program for one year. |
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Tuition |
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Books |
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Room/Board |
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Travel |
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Other |
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TOTAL |
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RESOURCES AVAILABLE: |
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Other Scholarships |
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Pell Grant |
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Employment |
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Loans |
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Family Assistance |
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Reserves |
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Other |
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TOTAL |
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