SDS Award Application (MTSU – School of Nursing)

Deadline: July 15, 2003 at 4:30 pm for Fall awards. Applications will be accepted until 4:30 pm on September 3, 2003 for award of any remaining funds.

Name _________________________________________________ Date___________

Address _______________________________________________________________

City ______________________________ State ____________Zip _________________

SSN ______________________________ email _______________________________

1. Are you a full time pre-nursing or nursing student? _______

2. Are you a citizen or national of the United States, or a lawful permanent resident of the United States, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, Guam, American Samoa or the Trust Territory of the Pacific? ________

A student who remains in this country on a student or visitor’s visa is not eligible.

3. Do you have a current application (FAFSA) on file in the Financial Aid Office? ____

4. Do you come from an environment that has inhibited you from obtaining the knowledge, skill and abilities to enroll in and graduate from nursing school? If so, explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Examples of environmentally disadvantaged students include but are not limited to:

_____ Member of a racial and/or ethnic minority

_____ Single parent head of household

_____ Graduated from a rural or inner city high school

_____ Have a physical disability

_____ First generation in your family to attend college

_____ Come from a non-professional family

5. Do you qualify for SDS assistance based on income? ________________

Your family must be a low-income family according to the scale below:

Size of family	Income*
1	$18,000
2	24,200
3	30,500
4	36,800
5	43,100
6 or more	49,400

* means number of exemptions listed on parents' Federal income tax forms
(e.g. family size of 4 might include two parents and two dependents).
** Adjusted gross income for calendar year 2002, rounded to nearest $100

6. Are you participating in the FACES (Nursing Workforce Diversity) Project? ___________ if yes, please explain ____________________________________________________
____________________________________________________________________________________________________________________________________________

On the back of this form, write a brief statement explaining your financial need and how receiving a scholarship would benefit you. Be specific.

Documentation of eligibility must be attached. Examples: Tax Return, High School Transcript, Notarized Statement, Physician’s Statement, etc.