ASCLS-AND.ORG

American Society for Clinical Laboratory Science

(Arizona/Nevada chapter of the ASCLS)
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Scholarship Form

STUDENT SCHOLARSHIP ON-LINE APPLICATION       

* indicates required field 

This application may be submitted on line by clicking the submit button after answering all the questions below.


* Name:       ASCLS#:  

* Address:   

* City:            * State:           

* ZipCode:       

* Phone:        * E-mail:   


Education:

A. * College or University presently attending:  

B. Expected graduation date:        

C. Other Colleges attended (please include dates):

D. * Cumulative GPA:    

Please request a Letter of Recommendation from a faculty member of your current institution. This letter must include confirmation of academic standing and competency.

Submit letters to: 
     ASCLS-AND
     PO Box 2271
     Scottsdale, AZ 85252
or email to: Susan Radley


Financial Statement:

A. Parental Support (annual): $   

B. Spousal Support (annual): $   

C. * Applicant's Total Annual Income (BEFORE taxes and other deductions):  $  

D. Financial Aid in the last year and for the upcoming semester which does NOT require repayment.
(scholarships, grants, GI benefits, disability, etc.): $   

E. Financial Aid in the last year and for the upcoming semester which DOES require repayment
(student loans, personal loans, etc.):  $  

F. Anticipated Expenses Related to Coursework (for the upcoming semester)

Tuition and Fees: $      Books: $      Room and Board: $

Other Expenses (explain): $

G. If you are working, please state where you work, what you do, compensation, and how many hours you work per week.  If you are not working, please state why you have chosen not to work:


Participation in ASCLS-AND, ASCLS, and/or other volunteer activites:     

  

Please explain why you believe you should receive this scholarship. Include anything you feel that is relevant to your situation that has not been covered by this application. You may include living expenses that are not typical to the college experience, i.e.child care, loan repayment, or other obligations you are meeting. Please give the amount, and reason for any expenses.


Scholarships are designated to be used for a specific semester in a Clinical Laboratory Science program. If for some reason the recipient does not begin or complete the respective program for the semester for which they received the funding, the money must be returned in its entirety to ASCLS-AND.

Privacy Statement: Information requested is affected by the privacy Act of 1971. This information is required to select applicants for ASCLS-AND scholarships. The information will be used to evaluate an applicant's eligibility and financial need. Disclosure is voluntary; however, the application process may be hindered without all requested information.

 I confirm that I have duly read the above information, and understand fully the intent of this scholarship. I further attest to the truthfulness of all data submitted. 

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American Society For Clinical Laboratory Science
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