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Justin J. Slama Memorial Scholarship
Online Application Form
*	First Name:
*	Last Name:
*	Address 1:
	Address 2:
*	City:
*	State:
*	Zip Code:
*	Daytime Phone:
*	E-mail Address
*	High School Attended:
*	Year Graduated:
*	Select county in which you reside: (Limited to: Cuming,Dakota, Dixon, Thurston and Wayne)	CumingDakotaDixonThurstonWayne
*	Are you a resident of Nebraska?	Yes     No
*	College Attending:
	ACADEMIC PERFORMANCE & HEALTHCARE EXPERIENCE:
*	College grade point average
	College transcript and copy of acceptance letter or notification of acceptance must be submitted. If not submitted, please give explanation. Submit copies to: Justin J. Slama Memorial Scholarship Pender Community Hospital Attn: Kelly Kaup PO Box 100 Pender, NE 68047
*	Healthcare Experience:
*	My career objective in three hundred words or less. Please relate your career objectives to the health needs of people living in rural areas.
*	College and community activities. (List activities, service clubs, work experience, etc.).
*	FINANCIAL NEED: Cost of program for one year.
	Tuition:
	Books:
	Room/Board:
	Travel:
	Other:
	TOTAL
	RESOURCES AVAILABLE:
	Other Scholarships
	Pell Grant:
	Employment:
	Loans:
	Family Assistance:
	Reserves:
	Other:
	TOTAL: