About Addiction Counseling Scholarship Application Form

About Addiction Counseling Scholarship Application Form
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Academic Information
Highest Grade Completed
Latest GWA Percentile
Are you currently registered with any agency as a Registered Counselor? Please provide information
Have you completed any of your CORE education requirements towards Certification? Please provide information
Education Information
Name of School
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

This is a fill in the blanks field. Please add appropriate blank fields and text.
Financial Information
Are you a dependent of your Parents?

YesNo
Annual Income
How many hours are you willing to commit to completing your education?

1-56-1011-20
There are 7 courses total. Are you willing to comply with the requirement of spending no more than 45 days on each course?

YesNo

Essay

Please respond to the following prompt in the space provided below: Tell us what inspired you to work with individuals with a Substance Use Disorder, what barriers may interfere with your ability to adhere to the program requirements and how you plan to overcome them. Minimum Word Requirement is 300 words.
Type a question
I AFFIRM THAT ALL STATEMENTS I HAVE INDICATED HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY MISREPRESENTATION I HAVE MADE CAN CAUSE FOR THE INVALIDATION OF MY APPLICATION AND SHALL BAR ME FROM RE-APPLYING FOR THE SAME.
Applicant's Signature

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Name of Applicant

First NameLast Name
Date Signed by Applicant

MonthDayYear
Date
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