Candidate’s Name
(required)
First Name
Last Name
Maiden Name
(if applicable)
Home Address (Street)
City/Town
State
Zip Code
Home Phone
Cell Phone
Email Address
(required)
St. Elizabeth’s Hospital SON Graduation Date
Professional Certificate Award
(maximum of $250.00 — certification renewed within the last twelve months; provide a dated copy of the certificate, a copy of the paid receipt, and a description of the certifying organization)
Date
Program Title
Date completed
Marian Scholarship Award
(maximum of $1,000.00 — for a graduate pursuing a nursing degree; monies must be used within twelve months of the award. If starting an accredited nursing program, send proof of acceptance. If already enrolled, send G.P.A.)
Are you currently enrolled in a post-secondary institution?
Yes
No
If yes, institution name and address
Specify degree being sought
Have you attended other post-secondary institutions?
Yes
No
Institution name and address
Have you been the recipient of any other scholarship funding?
Yes
No
If yes, please explain
Please write a short paragraph explaining your need for the Marian Scholarship aid
Signature
(type your full name)
Website
Please fill all required fields.
Submit
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