OREGON CANCER REGISTRARS ASSOCIATION MICHELE HENSON MEMORIAL SCHOLARSHIP FUND APPLICATION FORM Name Credentials Institution Phone _____________________________________________________________________________________ Address City, State, Zip Number of years employment or other involvement in a cancer registry: Number of years membership in OCRA: NCRA:_____________________ You must attach: 1) A brief summary of your work experience, education, AND goals. You may include anything else you feel is pertinent to this selection process. 2) A letter from your supervisor stating that your employer will not pay the examination fees. I certify that the information provided in this application is correct, and that: I am an active member of the Oregon Cancer Registrars Association in good standing. I am eligible to write the Certified Tumor Registrars examination according to NCRA criteria. www.ctrexam.org I am working full or part time in a cancer registry, which is part of a Cancer Program approved by, or striving for approval by, the Commission on Cancer. Signature of Applicant Date OCRA Standing Rule: → Two scholarships will be awarded to OCRA members to cover the cost of the NCRA CTR exam. → The amount of the scholarship will be equal to the exam registration fee. → One scholarship will be awarded for the spring and one for the fall exam. → The recipient will be notified the following month and announced in the newsletter. → The recipient will be reimbursed upon submitting documentation to the OCRA treasurer that the NCRA CTR exam has been completed. → The selection will be based on a brief written summary of the applicant's experience, education, goals, number of years as an OCRA member, and number of years employed or involved in a Cancer Registry. Return completed application to: OCRA Treasurer DEADLINE FOR POSTMARK/FAX: (Check which scholarship period you are applying for) _____ SPRING EXAM _____ ALL EXAM