Infusion Nurses Society
Scholarship Application
Please Note: Deadline for each scholarship is 30 days after the date of the event.

CRNI Sept. ____

Chapter Annual Seminar ___

National Educational Meeting ____

National Annual Meeting ____

National Academy-Spring ____

Name: _______________________________________________________________________________________
Address: _______________________________________________________________________________________
City, State, Zip Code: _______________________________________________________________________________________
Home Phone:                                                                 Email: _______________________________________________________________________________________

Current Position: _______________________________________________________________________________________
Employer:  _______________________________________________________________________________________
Nursing License #:                                             State:
_______________________________________________________________________________________

_______________________________________________________________________________________

1. Chapter Member:  Yes ___   NO ___ 4. Attended Bi-Monthly Mtg.  Yes ___   NO ___
2. INS Member Yes ___   NO ___ 5. Attended Annual Seminar Yes ___   NO ___
3. CRNI  Yes ___   NO ___  

Chapter Leadership:
                          
1. Elected Office Position Year  ____________

2. Appointed Committee Chair - Dates: ________________

3. Committee Member - Dates: ________________

4. Submitted Article for Newsletter - Dates: __________________

5. Recruited New Members - Names: _________________________________________________________

Print out this form and mail it to: NEC INS, C/O Jill Taylor, 18 Fuller Road, Middleton, MA 01949