Name: ______
THE DEADLINE TO SUBMIT SCHOLARSHIP APPLICATION: FRIDAY, OCTOBER 18, 2013
Please read the document labeled“Scholarship Criteria 2013”and only apply to those scholarships for which you are eligible.
Please check off the scholarship(s) for which you are applying:
Dental Alumni Association Scholarships
The Alan & Trudi Gardiner and Morton & Pearl LoweEndowed Scholarship Fund
William R. Cinotti Endowed Scholarship at RSDM
Dr. Rita Virmani Mehra Endowed Scholarship atRSDM
Estate of Edith Richards Endowed Scholarship
Eastern Dentists Insurance Company Scholarship
Carmine & Giuseppina Caruso MemorialScholarship
Edward Wolfson Endowment Fund
L. Deckle McLean Scholarship Fund
RSDM Endowed Memorial Scholarship
Joseph Pollack Endowed Scholarship Fund
RSDM-Hispanic Dental Association Award
Champions Endowed Scholarship
AT&T Minority Students Endowed Scholarship
Name: (Last name, First name, Middle name) / Date: / Class year:If record required for this application appears in any other name other than above, please indicate: / SS #:
Home address:
City: / State: / Zip:
Home phone: / Student ID:
Date of birth: / Place of birth:
Married: Single: / No. of dependents:
Your information: / Spouse information:
Company: / Company:
Address: / Address:
City/State/Zip: / City/State/Zip:
Telephone No.: / Telephone No.:
List of colleges or universities that you have attended with the dates that you were registered at each:
College or University:
Major of Study: / Attended from: to:
Degree Received:
College or University:
Major of Study: / Attended from: to:
Degree Received:
College or University:
Major of Study: / Attended from: to:
Degree Received:
Internships or Residencies (indicate location and date):
Grant/Loan: / Amount:
Grant/ Loan
/ Amount:Please answer the following questions:
- As a student at the School of Dental Medicine, how would you describe the Dental Alumni Association?
- The Dental Alumni Association would like to know about your experience at RSDM.Explain what you likemost or least about the dental school.
3. Do you plan on getting involved with the Dental Alumni Association? Explain how.
4. Do you plan on getting involved with organized dentistry in the future? Explain how.
Upon completion of this application, please review “Scholarship Criteria 2013” to ensure remittance of the appropriate documents
Please submit 1 original and 2 copies of the entire application
If there are extenuating circumstances that you feel the scholarship committee should be made aware of, please provide a brief summary (please do not exceed one additional page)
Please remember that all recommendation letters should be typed on Rutgers letterhead and signed by the faculty member (emails and copy of emails will not be accepted)
Submission and signing of this application constitute an attestation that the information provided above is true and accurate. By signing, you agree to having information about your grades and finances released to the members of the scholarship committee
Applicant’s Signature ______Date: ______
Please refer all questions to the Office of Student Affairs, Room B825
APPLICATIONS MUST BE COMPLETED AND SUBMITTED BY
5:00 P.M. ONFRIDAY, OCTOBER 18, 2013
Office of Student Affairs
110 Bergen Street – Room B825
Newark, NJ 07103-1709
(973) 972-5064