Scholarship Application Form

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Major:  Engineering, Health Systems  Engineering, specify type: ____________________________________ _ Engineering Technology, specify type: ____________________________   %LRPHGLFDOHTXLSPHQWWHFKQLFLDQVWXGHQW  Other, specify type: ___________________________________________ Briefly describe how you are financing your education: __________________ ___________________________________________________________________  RPSOHWHFRQWDFWLQIRUPDWLRQ & 1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $GGUHVVBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &LW\BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB6WDWHBBBBBBBBBB=LSBBBBBBBBB +RPH3KRQHBBBBBBBBBBBBBB(PDLOBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB (PSOR\PHQW+LVWRU\BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Undergraduate Institution ________________________________________________ Graduate Institution: __________________________________________________ &ROOHJH$FFUHGLWDWLRQ$JHQF\BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB &XPXODWLYH*3$BBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Expected Date of GraduationBBBBBBBBBBBBBBBBBBBB (Note: To be eligible graduation date must be after June 2017) List Degree Type: (Associate, Bachelors, Masters, etc): _BBBBBBBBBBBBBBBBBBBBBB $SSOLFDWLRQPDWHULDOUHTXLUHG  1. AFRPSOHWHG$SSOLFDWLRQ)RUPVXEPLWWHGE\DSSOLFDQW  2. 'RFXPHQWDWLRQRIDFFHSWDQFHRUSHQGLQJDFFHSWDQFHLQWRWKHDFDGHPLFSURJUDPDVD IXOOWLPHVWXGHQW$FRS\RI\RXUPRVWUHFHQWDFDGHPLFWUDQVFULSWIRUWKHDFFUHGLWHG FROOHJHRUWKHKLJKVFKRROWUDQVFULSW 3. $QHVVD\ZRUGV H[SODLQLQJKRZ\RXVHH\RXUVHOIILWWLQJLQWRWKHhealthcare technology, or healthcare systems engineering fieldhow you plan to use your degree in a healthcare technology setting, DQGKRZWKHscholarship would improve your college finances. Please describe evidence of academic excellence and other skills. 4. 7ZROHWWHUVRIUHFRPPHQGDWLRQIURPSURIHVVLRQDOFRQWDFWVDGGUHVVLQJZRUNHWKLFV attitude and potential contributions to the profession.  0DLO, or EmailDSSOLFDWLRQDQGVXSSRUWPDWHULDOWRWKHDGGUHVVEHORZ  A AMI Foundation Attn: Allison Rafti, Director, Membership Marketing 1)DLUID['ULYH6XLWH $UOLQJWRQ9$ 3KRQH253-8296 (PDLODrafti#DDPLRUJ