Maine Osteopathic Association < Scholarship Application>

Scholarship Application

Deadline: May 1st

Name of Applicant:
First: Middle: Last:
Social Security Number:

Expected Date of Graduation:

Number of Years as a Maine Resident (excluding college years):
(please provide proof - i.e. high school transcript)

Accepted or enrolled at: Osteopathic College

Home Address:
Street:
City: State: Zip:
Tel:

Current (Mailing) Address:
Same as Home address:
Street:
City: State: Zip:
Tel:

Marital status: Single Married Widowed Divorced
Spouse Name:
Occupation:
No. of Children:

Applicant's Date of Birth:
Birthplace:

Undergraduate College:
Degree: BA BS BFA
Major:

Graduate College (if any):
Degree: Field:

Military Service (Branch):
Air Force Army Coast Guard Marines Navy
Length of Service:
Discharge rating or rank:

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 Resources for Academic Year:

Expenses

Resources

Tuition & Fees $:

Books & Supplies $:

Room & Board $:

Transportation $:

Other (please specify) $:

Total $:

Savings Available $:

Family Contribution $:

Employment Income $:

Spouse Contribution $:

Other (please specify) $:

Total $:

If these columns do not balance, please describe sources from which you expect to obtain additional funds:

If you have a loan(s), please describe loan source and amount of loan (include any previous Maine 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: