Oregon APCO NENA - Scholarship Request Form

* Email Address

* Scholarship Request Select from available scholarship(s) below

* Is this Scholarship Request for you or on behalf of another applicant in your office? If other, please describe below

For Me
For Someone Else in My Agency
Other

Other

Nominator Name

Nominator Email

Name

Position Title

Agency/Organization

Email Address

Phone Number

Are you a Local or National Committee Chair?

Yes
No

Are you a Local or National Committee Member?

Yes
No

Have you been published in an APCO or NENA magazine?

Yes
No

Are you an APCO major award winner?

Yes
No

Why do you (or the person you are nominating) want to attend this training?

How will this training benefit your agency?

Have you been awarded a scholarship through Oregon APCO/NENA before?

Yes, multiple times
Yes, only once
No

If yes, advise the year of last awarded scholarship

Are you a member of APCO or NENA? (Non-membership does not directly disqualify you)

APCO and NENA
APCO only
NENA only

As part of this scholarship, please share what you need financial assistance with:

Class/Conference Registration
Lodging and/or Travel Expenses

If you indicated assistance for hotel and/or travel, please estimate your travel/lodging costs.