EDWARD P. DOLBEY GRADUATE SCHOLARSHIP APPLICATION

Name ______________________________________________________________________

Address ___________________________________________________________________

City ______________________________  State _________  Zip __________________

ASCLS Member # _________________     Year joined _______________________

Certification(s) __________________________________________________________

Home phone ________________________     Work phone _________________________

E-mail ____________________________________     Fax ____________________________

EXPERIENCE

Place of employment, listing the most recent First

 Positions held and dates Brief discussion of duties                               
 

 

 

 

 

 

    

EDUCATION

Name of college/University Degree earned (proof required) Date of completion
 

 

 

 

    
Name of clinical laboratory program Degree or certificate earned Date of completion
 

 

 

    

PROFESSIONAL ACTIVITIES: Please list the following on a separate page.  Include offices

held, committees Chaired, serving as a committee member, and projects in which you

actively participated.

  • Local chapter

  • Constituent society (include professional meetings attended)

  • ASCLS (include professional meetings attended)

  • Publications

  • Community education and/or projects advancing public awareness of health and/or                                                          clinical laboratory science

  • Presentations given such as talks, seminars, workshops

EDUCATIONAL INSTITUTION ENROLLED IN OR PLANNING TO ENROLL IN:

Name of University, college, or school ________________________________________________________

Address _____________________________________________________________________________________

______________________________________________________________________________________________

Type of Degree _____________________________________________________

Major _______________________________________________________________

Include on a separate page, a statement describing how the additional education

will better prepare you for future service in, and contribution to clinical laboratory

science.

 

PROOF OF SUCCESSFUL COMPLETION: I understand that proof of successful

completion of course work for the year immediately following the award must be

submitted prior to the next ASCLS-PA Annual Meeting (usually held in April each

year).  Proof may be in the form of the transcript or a signed statement from the

course instructor.  If proof of successful completion is not submitted and/or

courses taken and/or grades received are not acceptable for degree requirements,

I shall return the scholarship money to the Edward P. Dolbey Scholarship Fund

of ASCLS-PA.

Signature of applicant ________________________________________  Date _____________

 

ATTACHMENTS:

1.    Essay, wherein you focus on why this additional education will prepare you

for future service in clinical laboratory science.                                                                                

2.    Listing of professional activities.  Copies of curriculum vitae are not accepted.

 

UNDER SEPARATE COVER:

1.    Official document showing proof of completion of most recent highest degree received.

 

Send completed application to:    Nellie Bering

                                                                  4000 Gypsy Lane, #342

                                                                  Philadelphia, PA 19129-5424

This website last modified 01/30/2007