Michigan NENA Scholarship Application
PROGRAM YOU ARE REQUESTING: StateConference _____ National Conference _____
NENA Member #__________________________________________________________________
Last Name__________________________ First Name _________________________________
Title_____________________________________________________________________________
Agency Name______________________________________________________________________
Address___________________________________________________________________________
City / State / Zip____________________________________________________________________
Telephone__________________________ Fax ___________________________________
E-Mail____________________________________________________________________________
How will attending this program benefit you asa 9-1-1 / Public Safety Professional?
___________________________________________________________________________________
___________________________________________________________________________________
How will this program benefit your agency orcounty?
___________________________________________________________________________________
___________________________________________________________________________________
Number of years in current position: _________ Number of years in PublicSafety: _________
Briefly describe your current responsibilities:______________________________________________
___________________________________________________________________________________
APPLICANTS SIGNATURE ____________________________________________________________
RETURN COMPLETED FORM TO:
Andrew B. Goldberger, Treasurer
Michigan Chapter of NENA
St. Joseph County Central Dispatch 9-1-1
620 E. Main Street, P. O. Box 66
Centerville, Michigan 49032-0066
Voice: (616) 467-4195 Fax: (616) 467-4375