Roy Blunt Behavioral Health Scholarship Application

* Disclaimer, Assurances, & Signature 
    
I certify the information contained in this application is true and accurate to the best of my knowledge. I understand that any false or misleading information may result in the rejection of my application or my disqualification from the Program if I am selected for participation. I authorize the Missouri Behavioral Health Council ("the Council") to investigate any of the facts set forth in this application. I further understand that the Council may contact the persons providing my letters of recommendation or who have knowledge of my student, resident, or work experiences to conduct a background investigation. I hereby authorize and request any personal references and other persons, firms or entities to furnish the Council any information regarding my work and service. I hereby release all persons, companies, corporations or individuals from all liability and responsibility that may result from providing the Council such information.

I also verify that I intend to complete my academic program and work in Missouri after graduation.  

The submission of this application will indicate your understanding and signature. 
If you understand the above statement, please type full name in Comment Box.