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Full Name*

Date of Birth*

E-mail Address*

Phone Number*

Street Address*

City* State*

Zip Code*

College/University

College/University Name

Degree Attained

Dates Attended

Graduation Date

GPA

College/University Name

Degree Attained

Dates Attended

Graduation Date

GPA

College/University Name

Degree Attained

Dates Attended

Graduation Date

GPA

If you have been enrolled in any other vocational, trade or professional school, list them below.

High School

High School Name

Degree Attained

Dates Attended

Graduation Date

GPA

Employment Background

Employer

Employer Address

Employment Dates

Description of Duties

Employer

Employer Address

Employment Dates

Description of Duties

Employer

Employer Address

Employment Dates

Description of Duties

Involvement/Accomplishments

List memberships or affiliations with any professional, civic or volunteer groups.

List awards, scholarships or honors you have received.

Have you applied for other scholarships or employee tuition reimbursement program?

Attach short essay.*

Attach an acceptance letter from an educational institution nursing program.*

Understanding of Floyd’s Nursing Scholarship

The above statements are true to the best of my knowledge. I understand that any scholarship awarded to me may be revoked if any statement(s) is found to be false. I understand that if I am awarded a scholarship, I would be rewarded with a check for $1,500.00 made payable to me for each quarter/semester attended, not to exceed $3,000.00 in a year, and that I will be required to sign a contract agreeing to work for Floyd or pay back the scholarship upon graduation.

I understand that my academic records will be evaluated by Floyd after completion of each semester to ensure academic standards are met to maintain the scholarship. If I do not meet the required academic standards, I understand this scholarship will be revoked and I will need to begin paying back the received scholarship amount. I understand that any scholarship awarded to me and the amount awarded is subject to the availability of funds.

I fully understand the Floyd Nursing Scholarship terms and conditions. *