Georgia Association of
Nursing Student
Mary Long - BTN Scholarship
Name:  ____________________________________________________________________________

Address:  __________________________________________________________________________

City:  __________________________________    State:  _______________     ZIP:  ______________

Phone:  ___________________________    SSN:  _________________________________________

School of Nursing:  ___________________________________________________________________

Type of Program:  ___________________________________________________________________

Year in School (circle one):           Freshman             Sophomore             Junior             Senior

Graduation Date:  ________________________________

Describe the BTN activities you have been involved in:




































Reasons for applying for this scholarship:
Important
Enclose the following information with this application:

     1.  A photocopy of your NSNA membership card.
     2.  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]
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