Research Utilization Award: Application Form

Title of the Research Innovation:
_____________________________________________________________________

_____________________________________________________________________

Dates of innovation implementation: ________________________________________

Site where innovation took place:___________________________________________

Name of Applicant (Eta Omega Member):______________________________________

Degrees: _________________________________

Professional Title and Affiliation: __________________________________________

Address:

__________________________________
_____________________________________
_____________________________________

Telephone:

home

work

Signature of Applicant: _________________________________________________

Date submitted: _________________________________________

If group submission, list others involved:

Name:_________________________________ Degrees: ______________

Name:_________________________________ Degrees: ______________

Name:_________________________________ Degrees: ______________

Name:_________________________________ Degrees: ______________

Names of persons submitting letters of support:

1. Name:________________________________________________________

   Professional Title and Affiliation:__________________________________

2. Name:___________________________________________

Professional Title and Affiliation:__________________________________

Revised 5/98