NAHSL 2001 Scholarship Application

Name:_____________________________________________________________________

Job Title:___________________________________________________________________

Library:________________________________________ Full Time _____ Part Time _____

Organization: _______________________________________________________________

Address:___________________________________________________________________

              ____________________________________________________________________

              ____________________________________________________________________

 Phone: __________________________________

 Program Title: ______________________________________________________________

 Location: __________________________________________________________________

                  __________________________________________________________________

                  __________________________________________________________________

 Course/Program Fee: ________________________________

 Total Scholarship Requested: _________________________

 Please indicate your departmental CE budget _____________________________________

 Are any institutional CE funds available to you? ___________________________________

Signature: ___________________________________________________________________

Date: ____________________

Mail To:             Kathy Brunjes, NAHSL Secretary

   Central Maine Medical Center

   Gerrish-True Health Sciences Library

   Box 4500, 300 Main Street

   Lewiston, ME 04240

Telephone: 207-795-2561               Fax: 207-795-2569              Email: brunjesk@cmhc.org

Please note:  All Scholarship Applications must be received by September 30, 2000.