2023 Scholarship Awards Application Form

2023 Scholarship Awards Application Form
Deadline: April 15, 2023
Name*

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

Street Address

Street Address Line 2

City State

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

YesNo
Year Joined:*
Head of Household:

FatherMotherSelfOther
Others You Support:

123 or More
Support 1

Name Relationship, Age School or Place of Employment
Support 2

Name Relationship, Age School or Place of Employment
Support 3

Name Relationship, Age School 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 Numbeer State

Zip Code
Anticipated Source of Income/l i.e., Family,Scholarship, Grant, Loans, Veterans Benefits, etc.; please list:*
Are you a recipient of other scholarships for the coming academic year? If so, please list the scholarship and amount:*
Or Enter "No"
Are you eligible for free tuition or tuition assistance? (check all that apply)*
Please name the program and the amount eligible and/or percentage of tuition covered:
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

City State

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

LPN/LVNADN RNRN-BSNGeneric BSN (please answer next question)MastersDoctorate
For Generic Students: Accepted into the nursing program?*

YesNoDoes not apply
If in a Doctoral Program, indicate type of degree*

EdDDNPPhD
Focus Area of Nursing

No more than two (2) focus areas0/100
How many years do you have before graduating?*
How much will your tuition cost for the 2023-2024 academic year?*
Expected Graduation Date:*
Month/Year - Please provide a letter from the Registrar with anticipated date of graduation.
Advisor:*
Do you attend an Historically Black College or University?*

YesNo
Are you currently enrolled (only being accepted is not eligible to apply)?*

YesNo
If yes, are you enrolled full-time or part-time?*
Extracurricular/Community Activities (please list)*
Personal Statement Instructions (REQUIRED)

Each applicant must submit a personal statement/essay of 500 words or two pages, double-spaced maximum responding to the following statement: "An NBNA Scholarship will allow me to" (discuss career goals, area of focus, and how you will improve the health and social conditions of African Americans).
Afffirmation
- 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.
- The sponsor may ask for personal statement and picture of the awardee.
Signature

Clear
Date

MonthDay Year
Date
Click to upload professional headshot*
Click to upload Personal Statement/Essay*
An NBNA Scholarship will allow me to....
Click to upload Resume or CV*
Click to upload letter of recommendation from Dean/Faculty member*
Click to upload letter of recommendation from Chapter President/Vice President*
Click to upload letter from the Registrar*
Click to upload additional letters of recommendation*
NBNA Honor Pledge (REQUIRED)

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:*
Click to upload additional supporting documents:*
(Certificates, letters, articles)
Deadline: April 15, 2023
Before you click submit, please make sure you have all the items on this list checked off for being completed 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 scholarship application form.

2. Two letters of recommendation

Chapter Members:
- First letter from your Dean or current Faculty member attesting to your academic performance, enrollment, expected graduation, participation/involvement in activities, and future potential
- Second letter from your current NBNA Chapter President or Vice President attesting to your membership and involvement and participation in chapter meetings, activities, and programs
DIRECT Members:
- If you are a DIRECT member, you can submit a letter of recommendation from the closest NBNA Chapter President within your region who can attest to your involvement in NBNA activities. Most chapters have the ability to hold meetings and participate in other events virtually, so you are encouraged to join a chapter within your region
- The second letter of recommendation must be from your current Dean or Faculty member
3. One official copy of your current school transcript (sent directly to NBNA prior to the deadline). Applications without a transcript recevied by the deadline will not be reviewed by the Committee

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

5.   Two-page/500-word maximum Personal Statement/Essay

6.   Letter from Registrar verifying enrollment and expected date of graduation

7. 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 (Dean/Faculty member and Chapter President/Vice President)

3.      Resume or CV

4. Two-page/500-word maximum Personal Statement/Essay

5. Letter from Registrar verifying enrollment and expected date of graduation

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

Submit your high-resolution headshot photo to staff@nbna.org

Submission of Your Official School Transcript

Have your school send 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 April 15, 2023.)

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 APRIL 15, 2023.

TRANSCRIPT MUST ALSO BE RECEIVED AT THE NATIONAL OFFICE ON OR BEFORE APRIL 15, 2023 BY COB.

Use of Scholarship Funds

Scholarship funds can only be used for current or future tuition and fees (unless otherwise specified by the scholarship sponsor). Funds cannot be used for balances from a previous term before being selected for the scholarship.

Questions

Please direct all questions about the scholarship application process directly to Dr. Angelo Moore, Chair of the NBNA Scholarship and Awards Committee, via email at: moore.angelo@yahoo.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: Reginald Dillard, MSN, RN
School Name: Grand Valley State University
Department: School of Nursing
City, State: Allendale, MI
Full Chapter Name: Grand Rapids Black Nurses Association
Name*

First Name Middle Name or Initials Last Name
Credentials (if any)*
School Name

School Name

Department

City State

Zip Code
NBNA Chapter*
ATTENDANCE AT THE NATIONAL CONFERENCE

NBNA prefers the presence of all scholarship recipients at the National Conference to receive their awards in person, however travel funds are not available for most scholarshps.
Should be Empty:

2023 Scholarship Awards Application Form

Current School of Nursing Enrollment: