FSAS 2009
SCHOLARSHIP APPLICATION FORM
July 19 through July 23, 2009
University of North Florida
Jacksonville, Florida
A limited number of scholarships are available from the Florida School of Addictions Studies. Each scholarship covers the full cost of tuition plus meals and other activities that are part of the FSAS. Scholarships DO NOT INCLUDE THE COST OF DORM OR HOTEL ACCOMMODATIONS. Criteria for awarding the scholarships are: demonstrated financial need, interest, activity in the addictions field and willingness to share knowledge and experience gained with others. Applicants must agree to share their observations and impressions regarding the FSAS experience with the Scholarship Committee IN WRITING, at the end of the school and meet the criteria specified by the various agencies that donate scholarship funds (see details on reverse side).
To apply, please complete this form and return it to the FSAS Registrar by May 2, 2009. All applicants will be notified of the Scholarship Committee’s decision by June 13, 2009.
ALL INFORMATION SUBMITTED MUST BE LEGIBLE
PLEASE PRINT
ALL INFORMATION MUST BE LEGIBLE
Name: _____________________________________________ Degrees/Certificates Held:____________________________
First MI Last
License Number: _________________________ Licensing Agency: ______________________________________________
Mailing
Address:___________________________________________________________________________________________
P.O. Box, RR, or Street Address, Apt. # city state zip code
Home Phone: (___)_________________________ Home E-Mail:______________________________________________
Employer and/or School:________________________________ Program Name:__________________________________
Work Phone:(____)__________________________Work E-mail:_______________________________________________
Address:____________________________________________ City:_______________________ State:_____ Zip:_______
Supervisor’s Name:_______________________________________
I would like to attend the 28th Annual Florida School of Addictions Studies because: _________________________________
___________________________________________________________________________________________________
How many years have you attended the FSAS? #_____ How many times have you attended FSAS on scholarship? #______
My career goals in the field of addictions are: _______________________________________________________________
___________________________________________________________________________________________________
I need financial assistance to attend the Florida School of Addictions Studies because: ______________________________
___________________________________________________________________________________________________
Do you plan to attend a full 20-hour track or one or two 10-hour mini tracks?: 20-hour track:_____; 1 mini:____; 2 mini’s____
Applicant’s Signature:_________________________________________ Date:___________________________________
Acceptance of this scholarship binds the applicant to share his/her observations and impressions regarding the FSAS experience with the Scholarship Committee, in writing by July 23, 2009 (the close of the school). For consideration, please return this completed form and letter(s) of recommendation by Tuesday, May 2, 2009 to:
FSAS Scholarship Chair
1725 Art Museum Drive
Jacksonville, FL 32207
Telephone: 1-888-933-FSAS E-mail: fsas@nefsc.org Web Site: www.fsas.org
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