MICHAEL D. ANTONOVICH RN Student Scholarship
COUNTY OF LOS ANGELES DEPARTMENT OF HEALTH SERVICES
OFFICE OF NURSING AFFAIRES
APPLICATION FOR MICHAEL D. ANTONOVICH
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.
Click here to download Director's Signature Page
*First Name:
*Last Name:
M.I.:
Other Name Used:
*Email Address:
*Current Mailing Address:
*City:
*State:
*Zip:
*LA County Resident?
*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?
*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 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?
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.
Date:
mm/dd/yyyy
** Please print out this form for your record before submitting