LA County Department Of Health Services

MICHAEL D. ANTONOVICH RN Student Scholarship

COUNTY OF LOS ANGELES DEPARTMENT OF HEALTH SERVICES

REGISTERED NURSE (RN) STUDENT SCHOLARSHIP APPLICATION

ATTENTION Applicant:

1. It is the obligation of each applicant to ensure that his/her application includes the Nurse Program Director/Chairperson or Designee Recommendation Form is received prior to the interview.

2. Please click the link below to download the page for the Director's signature.

* First Name:

* Last Name:

M.I.:

Other Name Used:

* Email Address:

* Current Mailing Address:

* City:

*State:

*Zip:

*LA County Resident?

Yes No

*How long? (Years):

*Home Phone:

*Work Phone:

*Cell Phone:

Education

* Name Of Nursing School:

If Other Specify:

TO APPLICANT: Provide the Office of Nursing Affaires with an official sealed copy of your transcripts prior to the interview or on the date of the interview.

*When did you begin the nusring program?

Begin Month:

Begin Year:

*When did you expected date of graduation?

Graduation Month:

Graduation Year:

* How many units are required in your nursing program?

* How many units have you completed?

*Are these semester or quarter units?

Are these semester or quarter units?

Quarter Semester

* What is your current grade point averagae (GPA)?

* How did you hear about this scholarship program?

If Other Specify:

* What is your health care background?

* Which of hospitals / medical centers are you interestd in working for?

* What area of nursing are you interested in working for?

If other specify here:

REQUIREMENT: Each Antonovich Scholarship Recipient is required to commit to work for the Department of Health Sevices at our medical facilities as Registered Nurse for three (3) years.

* What movitivates you to become a nurse at LA County?(500 Character Essay)

*If you are chosen as a recipient of the scholarship, there is a three year commitment to work at one the of DHS medical facilities in our network. Are you willing to fulfill this requirement?

If you are chosen as a recipient of the scholarship, there is a three year commitment to work at one the of DHS medical facilities in our network. Are you willing to fulfill this requirement?

Yes No I Do Not Know

If you answered no or I don't know, please provide an explanation:

*To qualify for the scholarship you must either (a) citizen of the United States, or (b) a registered alien with government permission to work in this country. Does either statement (a) or (b) described your status as a resident of this country?

To qualify for the scholarship you must either (a) be a citizen of the United States, or (b) be a registered alien with government permission to work in this country. Does either statement (a) or (b) describe your status as a resident of this country?

Yes No

Certification of Applicant:I certify that all statements made in this application and on any attachments included are true and complete to the best of my knowledge. I understand that any false statement(s) of material facts or omissions may subject me to disqualification of dismissal.

Agreement

I Agree I Do Not Agree

Date:

mm/dd/yyyy

** Please print out this form for your record before submitting