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| Georgia Association of Nursing Student Karl Lipinski Scholarship Award |
| Name: ______________________________________________________________________________ Address: ____________________________________________________________________________ City: ______________________________________ State: ______________ ZIP: _____________ School of Nursing: _____________________________________________________________________ Type of Program: _____________________________________________________________________ Year in School (circle one): Freshman Sophomore Junior Senior Graduation Date: ___________________________________ NSNA / GANS Activities involved in: Community Service activities (please note if these were health related): Reasons for applying for this scholarship. Please include financial needs and goals to be accomplished in pursuit of professional career in nursing. (may need additional paper): |
| Important Enclose the following information with this application: 1. A photocopy of your NSNA membership card. 2. Official current transcript(s) SEALED. 3. Letter of recommendation. |
| I hereby certify that all information and statements made in this application were complete and accurate. |
| Signature: ________________________________ Date: ____________________________________ |
| All applications must be received by September 10, 2004 |
| Please send the complete application & attachments to: GANS Awards Committee c/o Traci Steinhauser 1727 Country Park Way Lawrenceville GA 30043 (404)432-7273 [email protected] |