Marilyn Willits Nursing Certifications Scholarship Application

Name:*
Employee Number: *
Address: *
City/State/Zip:*	, ,
Day Phone:*
Evening Phone:*
Email Address: *
Entity:*
Department/Unit:*
FTE Status: *
Years of Service:*
Are you a preceptor? *	Yes No
Are you seeking:	Initial Certification Recertification
Name of Certification that you are pursuing:
Name of Certifying organization:
Certification Information Resources Nursing Certification Specialties Standards
Cost of Certification Registration:

Patient Care Area/Department Involvement: (List most recent)
1. Name of Activity, Project or Committee:
Date(s) of Service:
Presenter/Poster/Champion:
Committee Chair?	Yes No
2. Name of Activity, Project or Committee:
Date(s) of Service:
Presenter/Poster/Champion:
Committee Chair?	Yes No
3. Name of Activity, Project or Committee:
Date(s) of Service:
Presenter/Poster/Champion:
Committee Chair?	Yes No
4. Name of Activity, Project or Committee:
Date(s) of Service:
Presenter/Poster/Champion:
Committee Chair?	Yes No
Professional Organizations: (List most recent)
1. Name of Organization:
Member since (date):
Officer?	Yes No
2. Name of Organization:
Member since (date):
Officer?	Yes No
3. Name of Organization:
Member since (date):
Officer?	Yes No
Community Involvement (List most recent)
1. Event Name
Date
Leadership Role?	Yes No
2. Event Name
Date
Leadership Role?	Yes No
3. Event Name
Date
Leadership Role?	Yes No

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