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Scholarship/Fellowship Nomination Form

To nominate a student for any 2014-2015 scholarship or fellowship, complete this form as indicated. Please forward any questions to Bonnie Cameron, headquarters operations administrator, 770-449-0461, ext. 105.

Please note: Membership numbers are listed on your monthly chapter roster. Nominations for all scholarships listed on this form except the John S.W. Fargher, Jr. Scholarship and Society for Health Systems Scholarship must be received by Nov. 15. The nomination deadline for the John S.W. Fargher, Jr. Scholarship is Sept. 1 and for the Society for Health Systems Scholarship is Dec. 1.

Fields marked in bold are required.

Only one form is needed to nominate a student for multiple awards. Please only nominate students for scholarships that truly apply to them.

 

The nominee's Information

 

Nominee's Name: 

 

 

Complete Mailing Address: 

 

 

Phone Number:

 

 

 E-mail Address: 

 

 

Chapter Number: 

 

Membership Number: 

 

Expected Graduation Date (mm/dd/yyyy):  

 

Does the nominee have a minimum cumulative GPA of 3.40 on a scale of 4.00 (3.00 for the Lisa Zaken Award for Excellence)? 

   

 

For UPS Minority Scholarship: Is the nominee African American, Hispanic, Asian, or Pacific Islander, American Indian or Alaska Native?

   

 


Your Information:

 

Nominator's Name: 

 

 

Nominator's Title: 

 

 

Norminator's School: 

 

 

Nominator's Full Mailing Address: 

 

 

Nominator's E-mail Address: 

 

 

Nominator's Chapter Number: