2021 Scholarship Awards Application Form

2021 Scholarship Awards Application Form
Deadline: May 1, 2021
Name*

First NameMiddle Name or Initial Last Name
Daytime Phone#:*
Email:*
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Social Security No.*
Place of Employment*
Annual Income*
Spouse's Place of Employment
Spouse's Annual Income
NBNA Member Chapter*
Are you an NBNA Student Member?:*

YesNo
Year Joined:*
Head of Household:

FatherMotherSelfOther
Others You Support:

123 or More
Support 1

NameRelationship, AgeSchool or Place of Employment
Support 2

NameRelationship, AgeSchool or Place of Employment
Support 3

NameRelationship, AgeSchool or Place of Employment
Do you currently hold a Nursing License?*

YesNo
License Type:

RNLPN
If Yes, License Number and State

Street Address

Street Address Line 2

License NumbeerState

Zip Code
Anticipated Source of Income/l i.e., Family, Scholarship, Grant, Loans, Veterans Benefits, etc. Please List:*
Current School of Nursing Enrollment:

(School listed below is where your official transcript should be mailed from)
Name:*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Dean/Director's Name*
School Phone*
Dean/Director Email*
example@example.com
Type of Nursing Program - Please select one:*

LPN/LVNRNBachelorsMastersDoctorate
If in a Doctoral Program, indicate type of degree*

EdDDNPPdDOther
Expected Graduation Date:*
Month/Year
Advisor:*
Do you attend an Historial Black College of University?*

YesNo
Extracurricular/Community Activities (list)*
Personal Statement Instructions (REQUIRED)

Each applicant must ubmit a personal tatment of 500 words maximum responding to the following statement: "An NBNA Scholarship will allow me to"
- I hereby affirm that the information provided is complete and true. Any false statement(s) will make my application null and void.
- Consent/willingness to publish photograph in NBNA Publications and/or NBNA website.
Signature

Clear
Date

MonthDayYear
Date
Click browse to upload Professional headshot*

Upload a File

Cancelof
Click browse to upload 2 page essay*

Upload a File

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Click the link below to print, sign, and upload Your NBNA Honor Pledge to complete your scholarship application.

NBNA Honor Pledge
Click here to upload signed Honors Pledge:*

Upload a File

Cancelof
Click here to upload supporting documents:*

Upload a File

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Before you click submit please make sure you have all the items on this list checked off for being complete or having been sent:*
General Instructions

Follow all instructions for preparation and submission of your application. The following is required for submission:

1. A completed JotForm application form.

2. Two letters of recommendation:

One letter from either your NBNA Chapter president (past or present), other chapter leader (past or present), or member (past or present), attesting to your membership and involvement at the chapter level.

If you are a DIRECT member you can submit a letter from any NBNA member who can attest to your involvement in NBNA-like activities or a letter from someone who can attest to your community volunteer and /or other activities.

The second letter can be from a teacher or work supervisor.

3. One official copy of your current school transcript (mailed directly to NBNA)

4. A copy of your current resume or CV (5 pages max)

5. Personal statement (500-word max)

6. Current high-resolution professional photo

Application Submission Instructions

Applications and supporting materials will ONLY be accepted electronically

Assemble the following materials and save as one pdf file (only pdf files will be accepted) with this file name FORMAT: (Your Last name – Scholarship Application), Ex: Jones - Scholarship Application

1.      Completed application form

2.      Two letters of recommendation

3.      Resume or CV

4.      Personal statement

Submit the pdf file via email using the same file name (Ex: Jones - Scholarship Application) in the Subject to: admin@nbna.org.

Submit your high-resolution head shot photo to the same email address.

Submission of Your Official School Transcript

Have your school mail your official transcript directly to:

NATIONAL BLACK NURSES ASSOCIATION

Attn: Scholarship Committee

8630 Fenton Street, Suite #910

Silver Spring, MD 20910

(Please contact your school in enough time to have the transcript post marked and received at the National Office before or by May 1, 2021)

RECEIPT OF APPLICATION AND ALL REQUIRED INFORMATION AS INDICATED ABOVE MUST BE RECEIVED VIA EMAIL BY CLOSE OF BUSINESS AT 5:00 PM (EST) ON OR BEFORE MAY 1, 2021.

TRANSCRIPT MUST ALSO BE RECEIVED AT THE NATIONAL OFFICE ON OR BEFORE MAY 1, 2021 BY COB.

Questions

Please direct all questions about the scholarship application process directly to Dr. Sheldon D. Fields, Chair of the NBNA Scholarship and Awards Committee via email at: Sheldon.Fields40@gmail.com.
Information needed for the NBNA Final Conference Program Book

If selected, the typed information below is how your name, credentials and school information will appear in the final conference program book.

Example:

Full Name and Credentials: Natalie Devine, MSN, RN
School Name: University of the District of Columbia
Department: School of Nursing
City, State: Washington, DC
Full Chapter Name: Black Nurses Assocation of Greater Washington, DC Area
Name*

First NameMiddle Name or InitialsLast Name
Credentials (if any)*
School Name

School Name

Department

CityState

Zip Code
NBNA Chapter*
ATTENDANCE AT THE NATIONAL CONFERENCE
- PhD scholarship award recipients are REQUIRED to attend the national conference as a condition of award acceptance at their own expense in order to receive their award in person.
- NBNA prefers the presence of all scholarship recipients at the National Conference to receive their awards in person, however travel funds are not available.
Should be Empty:

2021 Scholarship Awards Application Form

Current School of Nursing Enrollment: