Nursing Program

Scholarship Application Form

Scholarship Criteria and Instructions

Family Name/Last Name Required

First Name Required

Middle Name

Permanent Address: Required

City: Required

County: Required

State Required

ZIP Code Required ZIP or ZIP+4

Home Phone:

Work Phone:

Cell Phone:

Email Address: Required

Student ID#: Required 7-digit UHV ID #

Place of birth (State & County): Required

Date of Birth: Required

Are you a US Citizen? Required YesNo

Are you a permanent resident? Required YesNo

What is your legal state of residence? Required

Do you pay out-of-state fees? Required YesNo

What is your classification? Required New Student/Full Time
New Student/ Part TIme
Returning Student/Full TIme
Returning Student/Part Time

I am applying for: Required Johnson Nursing Scholarship
Johnsons Scholars Award
Both
Other

Expected Graduation Date Required (mm/dd/yyyy)

Have you applied for financial aid at UHV?Required YesNo

If yes, what type of financial aid did you apply for (check all that apply)
Grants
Scholarships
Student Loans

Community College/Diploma Program:

Please list any previous UHV Nursing Scholarships indicating the semester and amount, if any:

Have you submitted a Free Application for Federal Student Aid (FAFSA) with your most recent income statement? Required YesNo

NOTE: To be considered for University scholarships that stipulate a financial need you must complete a Free Application for Federal Student Aid (FAFSA).

Certification statement:
Unsigned and incomplete applications will not be considered. Information on this application is provided to all UHV Nursing Program Scholarships.

I certify that all of the statements made are true, complete, and correct to the best of my knowledge. Student authorizes UHV to release information concerning his/her award to any federal, institutional, and/or local organization as necessary for the administration of the awards, processing of the student’s application and submission of required reports. Required

Student’s Signature:

Date: