Leslee Harris Smith Scholarship Application Step 1 of 2 50% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Please Select I am a student I am a professional respiratory therapist School/Program City State Program Director/senior faculty member: First Last PhoneEmail Va. Dept. of Health Professions Respiratory Care Practitioner license no.: Complete section A or B below: SECTION ANBRC exam to be taken: SECTION BSchool: Degree City State Date Enrolled Expected graduation date Program Director/senior faculty member: First Last PhoneEmail All applications for the Leslee Harris Smith scholarship award must include documentation listed in the applicable requirements section of the scholarship award program. ALL APPLICANTS: I declare that I have completed this application and that it is true, correct and complete to the best of my knowledge and belief. I further declare that I am the sole author of the paper and PowerPoint presentation submitted for consideration. I understand that if awarded monies are used for an NBRC exam application, that exam must be taken: for a student, within 6 months of graduation; for a professional, within 6 months of receiving the award monies. SUBMIT APPLICATION and DOCUMENTS ELECTRONICALLY BY JULY 1 Digital Signature* Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.