Continuing Healthcare Education Scholarship Application Form

Name*

First Last

Date*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Length of residence/work in Chelan area:*

Course/Program you plan to take (no acronyms):*

Administer by:*

Attach copy of registration form:*

Max. file size: 50 MB.

Date & Location of course/program*

Number of C.E. Credits:*

Deadline for registration:*

Registration for Program/Course Expense:*

Meals included?*

Yes
No

Cost of Books:*

Have you received a Bragg Scholarship previously?*

Yes
No

If yes, what year?*

Educational Background*

School	Location	Dates	Field of Study	GPA

Employment History*

Employer	Address	Dates	Responsibilities

Current Position Title*

Is course required by employer?*

Yes
No

Is course required for certification in your current position?*

Yes
No

Is this an online course/program?*

Yes
No

Why are you applying for these funds?*

Explain your career goals and how this course/program will benefit health care:*

Are you available for a personal interview?*

Yes
No

I certify that to the best of my knowledge the information contained in this application is true and correct. I understand that this application will not be considered for review unless it is signed and dated. I also understand that no materials will be returned.*

Yes (digital signature)

Comments

This field is for validation purposes and should be left unchanged.

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