Medical School Scholarship Information Form for academic year 2012-2013

If you apply for a scholarship for ANY reason during academic year 2012-2013, you must submit this form electronically to . If you receive a scholarship for ANY reason ( research stipend, research presentation, domestic or international travel, conference attendance, etc.) during academic year 2012-2012, you must also submit this form electronically to. The Office of Student Affairs will only notify you byemail when/if you receive a scholarship.

YOU NEED TO SUBMIT THIS FORM ONLY ONCE DURING ACADEMIC YEAR 2012-2013; HOWEVER, IF YOU RECEIVE A SCHOLARSHIP, YOU MUST WRITE A “THANK- YOU” NOTE TO EVERYSCHOLARSHIP DONOR. SUBMIT THE “THANK YOU” NOTE IN PERSON TO THE STUDENT AFFAIRS OFFICE 367L OR ELECTRONICALLY TO .

Question / Answer
I will apply for this (these) scholarship(s)
or
I will receive this (these) scholarships(s):
Date and time:
Full name(Last, First, Middle):
Birth date (mm/dd/yyyy):
Marital status:
Current address:
Permanent address:
Email address:
Student badge #:
Mobile telephone #:
Current year in medical school (yyyy):
Anticipated month and year of graduation (mm/yyyy):
Place of birth (city, county, state, country):
Place of high school graduation
(city, county, state, country):
Place where parents live now (city, country, state, country):
Size of family household in which you grew up:
Family income in which you grew up:
($0-$25, 000; $25, 000-$50, 000; $50, 000-$75, 000;
$75, 000-$100, 000; >$100, 000)
Are you a Texas resident? Y/N
Are you a U.S. citizen? Y/N
Are you a permanent resident? Y/N/NA
Do (Did) you serve in the military? Y/N If yes, which branch?
If discharged from the military, type of discharge:
Language(s) other than English:

Honors and awards (including college to present):

Leadership activities (including college to present):

Teaching activities (including college to present):

Research activities (including college to present):

Volunteer/community activities (including college to present):

Extracurricular and leisure activities (including college to present):

Specialty interest(s):

Career goals:

After medical school and residency/fellowship training do you plan to practice medicine in a rural area or small town in Central or South Texas? Y/N If yes, in which city/county in Texas do you plan to practice medicine?

Explain briefly how a scholarship will benefit you:

********************************************************************************************************

If I receive a scholarship durnig academic 2012-2013, I give permission to the Medical Scholarship Committee/UTHSCSA Development Office to provide my personal information to the scholarship donor. I give permission to the MedicalSchool Scholarship Committee to access my academic record for evaluation purposes. I understand that, to be eligible to receive most scholarships, I must have already completed the 2010-2011 FAFSA form.

Signature: Date: ______

*For office use only: Name(s) of scholarship(s) received by student: