Permission for release of information:

 

I, _______________________________, give permission for the release of requested information to the Advance Practice Nurses of the Ozarks Scholarship Committee for the purpose of consideration of my application for an APNO Scholarship.

 

___________________________________________                      ______________

Signature of Applicant                                                               Date

 

Director/Dean:   The person identified above has submitted an application for a Scholarship from the Advance Practice Nurses of the Ozarks. Please provide the following information and return this form directly to APNO. Your prompt attention to this request will be appreciated as the application cannot be further evaluated without your input.

 

Has the applicant been admitted to the Graduate Nursing Program of your institution?

 

Is the above named applicant a student in good standing with your graduate nursing program?

 

Master’s degree or Post Master’s certificate student: has the above named applicant completed 12 credit hours of the requirements for graduation?

 

Master’s degree or Post Master’s certificate student: what is the cumulative GPA for the graduate level study by the student?

 

What is the anticipated date of graduation of the applicant?

 

_______________________________________________                          ___________

Signature of Dean/Director                                                                                           Date

University Name and Address

_______________________________________________             

Printed name

 

            RETURN FORM TO:              Advance Practice Nurses of the Ozarks

                                                               ATTN: Scholarship Committee

                                                               PO BOX 3216

                                                               Springfield, MO 65808