Scholarship Application

Name

Subject

Message

Phone Number

Is this is a...

Home Phone Number Cell Phone Number

Name of Employment

Address of Employment

Country

Address Line 1

Address Line 2

City

State

ZIP Code

Are you a NERBNA member?

Yes No

Are you a student member?

Yes No

Do you hold a Nursing license?

Yes No

If yes, please indicate which type

LNP RN

If yes, license number and State:

Education

Current Nursing School Enrollment (official transcript should be mailed)

School Address

Country

Address Line 1

Address Line 2

City

State

ZIP Code

Dean of School

School Phone Number

Expected date of graduation

Please list any extracurricular and/or community activities

I affirm that all the information provided is true.

Yes, the information I have profided is correct, true and verified

Today's Date

Application Documents:

Select all that apply that you will be emailed to NERBNA for review

Additional Information

The NERBNA scholarship application and supporting document deadline is February 16, 2024 at 5:00 pm.

Please email the application and supporting documents to nerbna72@gmail.com

Please have an official transcript mailed to: NERBNA Scholarship Committee Post Office Box 190690 Roxbury, MA 02119

Transcripts must be postmarked and received by February 6, 2026

New England Regional Black Nurses Association Scholarship Honor Code

By signing this form, I signify that I will be attending the nursing program that I have indicated on my application in the next fall semester of the scholarship awarded year. Furthermore, if I do not attend the indicated nursing program, I will notify NERBNA and return the scholarship money awarded. This form must be signed and returned with your application in order to receive a scholarship from NERBNA

Name (Serves as Electronic Signature)

First Name

Last Name

NERBNA Scholarship Information

NERBNA Scholarship Honor Code

2025-2026 Scholarship Application

Education

Application Documents:

Additional Information

Name (Serves as Electronic Signature)

Scholarship Application

NERBNA Scholarship Information

NERBNA Scholarship Honor Code

2025-2026 Scholarship Application

Education

Application Documents:

Additional Information

Name (Serves as Electronic Signature)

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