RMR Scholarship Application for WOCN Certification/Recertification
Date of application
Day
First Name
Year
Month
Street Address
State.
WOCN Member #.
Unit #
Phone.
Last Name.
Alternate Phone
Email
Alternate Email.
Employer
Job Title
Credentials
Select all specialties you are seeking certification or recertification:
Will your employer assist you with certification/recertification fees?
Supervisor
Employer Phone #
If so, please indicate the amount your employer will assist:. $
Have you received financial assistance from the RMR in the last 3 years?
If yes, Please indicate the date:
If awarded a scholarship, you will be required to donate time to the RMR within the year of the award:
Day
Year
Please indicate how you would donate your time:
Please provide any other information you would like the RMR WOCN to be aware of when considering this application
I, hereby affirm that the information provided by me is true to the best of my knowledge, and I will notify the RMR WOCN of any changes to this information.
*The RMR reserves the right to audit any application for a period up to one year from the date of any award.
Zip Code
You are required to submit a copy of your receipt of payment and your new certification award. Scholarship will be presented after the RMR Board of Directors has received verification that you have completed and passed the certification exam(s).
*Other ideas are encouraged and should be submitted to the Scholarship Committee for consideration.
