Scholarships 2010-2011
Name:
Street Address 1:
Street Address 2:
City:
State:
Zip Code:
Email Address:
Phone Number:
Degree Sought:
Department or Program:
Semester Seeking Support:
Estimated Request for Tuition:
Estimated Request for Books:
Estimated Number of Semesters to Receive Degree:
Are you currently registered with the NC Substance Abuse Professional Practice Board?
Are you currently working in a substance abuse prevention or treatment provider organization?
Are you currently working in a substance abuse prevention or treatment provider organization?
Are you currently employed in another human service agency?
If yes, please list and describe your present position: