Maine Oesteopathic Association Scholarship Application

APPLICATION DEADLINE IS MAY 15TH *** APPLICATION DEADLINE IS MAY 15TH

* - Indicates a required field

Applicant Information

First Name:

Middle Name:

Last Name:

Expected date of graduation:

Accepted or enrolled at: Osteopathic College

Number of years as a Maine Resident (excluding college)?

Home Address

Address:

City:

State:

Zip:

Home Telephone:

E-mail address:

Current (Mailing) Address (if different)

Address:

City:

State:

Zip:

Current Telephone:

Marital Information

Status:

Spouses Name:

Spouses Occupation:

Number of children:

College Information

Undergraduate College:

Major:

Degree:

Graduate College (if any):

Field:

Degree:

Military Information

Service Branch:

Length of Service:

Discharge Rating or Rank:

Achievements and Goals

PLEASE DESCRIBE YOUR MOST SIGNIFICANT AWARDS, HONORS, AND ACHIEVEMENTS AS AN UNDERGRADUATE OR GRADUATE STUDENT AND YOUR MOST RELEVANT CO-CURRICULAR, EXTRA-CURRICULAR AND WORK EXPERIENCES.

PLEASE DESCRIBE YOUR OBJECTIVES IN OSTEOPATHIC MEDICINE.

Financial Information

Estimated Expenses and Resouces for Academic Year:

Expenses
Tuition and Fees $:
Books and Supplies $:
Room and Board $:
Transportation $:
Other (please specify below) $:

Total $:

Resources
Savings Available $:
Family Contribution $:
Employment Income $:
Spouse Contribution $:
Other (please specify below) $:

Total $:

If the totals do not match, please describe sources from which you expect to obtain additional funds. Also, please explain any amounts in the Other fields.

If you have a loan or loans, please describe the loan source(s) including any previous Student Loans.

This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of the signature, preceded and followed by the forward slash (/) symbol. Acceptable "signatures" could include: /john doe/; /jd/; and /123-4567/. For example: if your name is John Doe , you could type /John Doe/ below.

Signature:

Please Note: For security reasons certain information is not collected online through this form. Specifically Date of Birth and Social Security Number. You will be contacted to obtain them and any other supporting information needed to complete your application. Please enter the best way (and time) to contact you so that we can complete your application.

Contact:

APPLICATION DEADLINE IS MAY 15TH *** APPLICATION DEADLINE IS MAY 15TH