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 MICHAEL D. ANTONOVICH RN Student Scholarship

  
COUNTY OF LOS ANGELES DEPARTMENT OF HEALTH SERVICES
OFFICE OF NURSING AFFAIRS
APPLICATION FOR MICHAEL D. ANTONOVICH
REGISTERED NURSE (RN) STUDENT SCHOLARSHIP APPLICATION
ATTENTION  Applicant:
1.  It is the obligation of each applicant to ensure that his/her application includes the Nurse Program Director/Chairperson or Designee Recommendation Form is received prior to the interview.
2.  Please click the link below to download the page for the Director's signature.  
Download Director's Signature Page
Last Name: First Name: M.I.:
Other Names Used: Email Address:
Current Mailing Address:
City: State: Zip: L.A. County Resident: How Long? (Years):
 yrs
Telephone Numbers: Home: Work: Cell:
EDUCATION
NAME OF THE NURSING SCHOOL
If other specify   ---> 
TO APPLICANT: Provide the Office of Nursing Affairs with an official sealed copy of your transcripts prior to the interview or on the date of the interview.
MONTH YEAR
When did you begin the nursing program?
When is your expected date of graduation?
NUMBER OF UNITS
How many units are required in your nursing program?
How many units in nursing have you completed?
Are these semester or quarter units?
What is your current grade point average (GPA)?
How did you hear about this scholarship program?
(If other specify) 
What is your health care background?
Which of our hospitals / medical centers are you interested in working for?
What area of nursing are you interested in working for?
If other specify here ---> 
REQUIREMENT: Each Antonovich Scholarship Recipient is required to commit to work for the Department of Health Services at our medical facilities as a Registered Nurse for three (3) years.
What motivates you to become a nurse at LA County? (500 Character Essay)
If you are chosen as a recipient of the scholarship, there is a three year commitment to work at one ot the DHS medical facilities in our network. Are you willing to fulfill this requirement? 
If you answered no or I don't know, please provide an explanation:
To qualify for the scholarship you must be either (a) citizen of the United States, or (b) a registered alien with government permission to work in this country. Does either statement (a) or (b) describe your status as a resident of this country? 
 
Certification of Applicant:  I certify that all statements made in this application and on any attachments included are true and complete to the best of my knowledge. I understand that any false statment(s) of material facts or omissions may subject me to disqualification of dismissal. 
 
Date:
**  Please print out this form for your record before submitting.