NEW JERSEY REHABILITATION ASSOCIATION

       A chapter of the National Rehabilitation Association

Scholarship Application

Applicant’s Name:  _______________________Date: ______________

Home Address:   

______________________________________________________

                                  ______________________________________________________

Business Address:   ______________________________________________________

                                  ______________________________________________________

Telephone Numbers: (home) _______________   (work) ____________________

E-mail Address:  _______________________________

NRA Member #:  _______________________________

Amount of Scholarship Request: __________________

Describe how this scholarship would be applied (include the name/sponsor of event,

dates, location, registration, travel expenses, etc.):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why should you be considered for this scholarship?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Important note: Anyone receiving scholarship support from NJRA will be expected to make a report to the Board at the meeting following the event and to write an article for the NJRA newsletter, The Rehab Reporter.  It is also expected that scholarship recipients will become active on one of the NJRA Committees for one year.

Date Application Received by Board:   _________________________________

Board Decision:  ____________________________________________________

Chapter President Signature: _______________________________________________