2010 Student Scholarship Application Form
(Click Gray Boxes to Enter Text Electronically and to Select Appropriate Check Boxes)
Name of Applicant:
PID:
(Last)
(First)
Block I
Block II
Please check (X) to indicate that
you have attached the required
additional documentation for the
specific scholarship.
Year III
Year IV
Please List The Scholarships For Which You Are Applying
1.
2.
3.
4.
5.
6.
7.
8.
Letter of Recommendation
Please list the name of the individual who will provide a letter of recommendation on your behalf for your
scholarship application. Only one (1) letter of recommendation is allowed. Please provide your evaluator the
attached Confidentiality Form for the Letter of Recommendation. This form should be attached to the letter of
recommendation. The letter must be received by the application deadline.
(Name of Evaluator
Unit/Organization
Email Address)
All applicants must be in good academic standing in the College of Human Medicine (not under
academic review, on probation or in a dismissal status). Please carefully review the eligibility and selection
criteria for each scholarship to determine that you meet the stated eligibility criteria for each specific scholarship
for which you are applying. You are responsible for providing any required additional documentation for
the specific scholarships for which you apply. Email questions regarding the application to:
CHMstudentaffairs@hc.msu.edu
Please return the completed application form and all supporting documentation addressed to the Office of
Student Affairs and Services OR the Office of the CHM Community Assistant Dean no later than:
Friday, January 29, 2010
(Handwritten applications will not be accepted. All applications must be typed or printed
from a computer)
Indicate Date Received and Initial:_____________
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Name of Applicant:
I. STUDENT PERSONAL INFORMATION
A. Family Status
Single
Married
Children: Number
Ages:
B. Background
Financially Disadvantaged
Rural
Urban/Inner City
Person w/Disability
C. Did you attend a Michigan High School?
Yes
No
Please check if you attended high school in one of the following Michigan counties:
Branch
Eaton
Ingham
Oakland
Calhoun
Genesee
Kalamazoo
Shiawassee
Clinton
Huron
Lapeer
Tuscola
D. Are you a Michigan State University Graduate?
Yes
No
E. What Michigan County do you currently reside in?
F. Did you enter medical school directly from college?
Yes
No
If no, please indicate how many years have passed since your completion of the undergraduate degree and your entry
into medical school and briefly describe your activities during this period of time.
II. PRACTICE PLANS
A. Do you plan to practice in Michigan?
Yes
No
Undecided
B. Please check the type of practice area you plan to enter:
Urban/Large metropolitan area
Rural Area
Medically under-served area
Yet to be determined
C. Please check the medical discipline in which you plan to specialize:
Anesthesiology
Family Practice
Obstetrics/Gynecology
Psychiatry
Other
Dermatology
Internal Medicine
Pathology
Radiology
Undecided
Emergency Medicine
Neurology
Pediatrics
Surgery
III. ACADEMIC INFORMATION
A. Please list the clerkships that you received Clinical Honors Designations (Block III Students Only).
B. Were you selected for Alpha Omega Alpha (AOA) Honor Medical Society?
C. Were you selected for the Gold Humanism Society?
Page 2 of 5
Yes
Yes
No
No
Name of Applicant:
D. Please provide other evidence of outstanding academic achievement during medical school including past
scholarships and awards.
E. Please address any extensions or leaves during your matriculation at the College of Human Medicine.
IV. COMMUNITY SERVICE AND VOLUNTEER ACTIVITIES AND EXPERIENCES DURING MEDICAL
SCHOOL
Please list and describe your community service and volunteer activities during medical school. Please list in reverse
chronological order beginning with most recent activities. (List medical school activities only)
Estimated amount of
Description of your involvement and
Inclusive dates of
Activity
time spent on
responsibilities for activity
activity
activity
Page 3 of 5
Name of Applicant:
V. LEADERSHIP EXPERIENCES
Please list and describe your leadership experiences during medical school. Please list in reverse chronological order
beginning with your current activities during medical school.
Estimated amount of
Description of position held and
Leadership
Organization
time spent in activity
statement of your greatest
Position
accomplishment in the position
VI. RESEARCH
Please list your involvement in any research projects during medical school.
Research project title and description of your work
Inclusive dates
on the project
Faculty Mentor/Supervisor
VII. PUBLICATIONS AND PRESENTATIONS
Please list scholarly publications and professional presentations during medical school.
Research project title and
Inclusive dates
description of your work on the project
Page 4 of 5
Faculty Mentor/Supervisor
Name of Applicant:
VIII. List any CHM Scholarships you have received in the past and the year received.
IX. Describe any extenuating family and/or personal circumstances that contribute to your financial
need.
I certify that I am in good academic standing and I have reviewed the information on this application
and certify that it is true and accurate. Furthermore, I authorize the College of Human Medicine to
release my academic record and the MSU Office of Financial Aid to release my financial information
to the Office of Student Affairs and Services and the CHM Student Scholarship Selection Committee
for review during the selection process.
If I am selected to receive a scholarship, I agree to write a thank you letter of acknowledgment to the
donor within two weeks of receipt of notification of the award. I understand that I will be expected
to attend the CHM Student Awards Banquet, Friday evening, April 16, 2010 in East Lansing
unless there is an emergency or other extenuating circumstance.
Please print name:
Signature of Applicant: ___________________________________
I certify that I am submitting this form electronically and the email that accompanies it may
serve as my electronic signature.
Please submit an electronic picture with your application. You may also provide an actual picture if
submitting your application in hard copy. The picture will be used for the CHM Awards Banquet
Program Book. Please indicate below what picture you would like the Office of Student Affairs
and Services to use.
I have attached a picture for use by the Office of Student Affairs and Services.
I would like the Office of Student Affairs and Services to use my CHM picture on file.
Please return the completed application form and all supporting documentation addressed to the CHM
Student Scholarship Selection Committee no later than:
Friday, January 29, 2010
E-mail Electronic Submission to: CHMStudentAffairs@chm.msu.edu
OR
You may either return your materials to:
Michigan State University
College of Human Medicine
Office of Student Affairs and Services
A234 Life Sciences Building
East Lansing, MI 48824-1317
OR
Submit to: CHM Office of the Community Assistant Dean
Flint – Grand Rapids – Kalamazoo – Lansing – Saginaw – Traverse City – Upper Peninsula
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