Note: Due to
funding limitations new applications are not being accepted until
further notice.
Applicant's Name:
Residence Address:
Residence City, State, Zip Code:
Phone:
Email:
Other contact information in case we
need to reach you:
RNs Only:
RN License Number:
State of Issuance:
Expiration Date:
By signing below, I
verify I have read and understand the South Dakota State University
College
of Nursing Wokunze Project 2007-2008 Student Scholarship Information. I
verify my application information is true and accurate and that I meet
eligibility and application requirements outlined in
the Wokunze Project 2006-2007 Student Scholarship Information. I also
verify I am not a current
IHS scholarship recipient or currently fulfilling an IHS loan repayment
or scholarship obligation.
By signing below, I
authorize SDSU Wokunze Project staff to make reasonable efforts to
confirm
any information I have presented as part of my application. I also
understand that by accepting a scholarship, I agree to serve a period of
obligated service to the Indian Health Service of one year
for each year (or portion thereof) of scholarship support received, and
to serve not less than 2
years of obligated service. If my application is approved, I understand
I must sign an Indian
Health Service Nursing Scholarship Contract agreeing to these conditions
before I will receive
funding.
Signature:
Date:
Instructions:
Submit all required application materials to:
Dr. Thomas Stenvig, Wokunze Project
Director
South Dakota State University
College of Nursing
Box 2275
Brookings, SD 57007
