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Event:_____________________________________
Place of Event:______________________________
Date of Event:______________________________
Benefit to Educator: _________________________
__________________________________________
Fee:______________________________________
Registration Deadline:_______________________
Please Attach Copy of Registration form and/or Flyer.
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Scholarship
Application
Name:
_________________Title: (RN, RD, CDE etc)______
Street Address:_____________________________________
City:
________________________, Wyoming, Zip:
_______
Phone-
Home (307) _____________Mobile: (307)__________
E-mail:_____________________________________________
Employer:
__________________________________________
Print Application and Send
to: WyADE
(At least 4 weeks in advance)
Through
education we can make a difference!
Reviewed by:_____________
Approved: ___; Declined: ___
Date Check Sent: _________Check Number: ___________
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