Greensboro Medical Society
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GMS Serves
Scholarship GALA
Store
Contact Us
If you have any questions or concerns, please contact us.
336-517-7230 - phone
contact@greensboromedicalsociety.com
Medical / Dental Preparation Scholarship Application Details
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Indicates required field
Name of Test Prep Applicant
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First
Last
Date of Birth
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Gender
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Male
Female
City / State of Birth
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Email
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Phone Number
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US Citizenship
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Yes
No
Upload Photo
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Max file size: 20MB
Mailing AddressMailing Address For Check Distribution
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Line 1
Line 2
City
State
Zip Code
Country
Planned year of application to medical/dental school (ex. Fall 20xx or Spring 20xx)
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How did you find out about The Greensboro Medical Society Foundation Scholarship program? If a Society doctor referred you, please indicate his/her name and relationship
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Educational History:College or University level (List current or most recent first).
Institution 1
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City / State
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Degree
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Dates Attended (Month and Year)
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Field of Study
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GPA
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List Pre-Med / Dental Courses Completed
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Institution 2
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City / State
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Degree
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Dates Attended (Month and Year)
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GPA
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List Pre-Med / Dental Courses Completed
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High School (Name and Location)
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Degree
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Employment History
Name of employer and address (List current or most recent first):
Employer 1
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Job Title and Type of Work
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Employment Dates (Start and Finish)
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Employer 2
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Job Title and Type of Work
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Employment Dates (Start and Finish)
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Extracurricular Activities
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Leadership positions in college
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Personal Reference of two individuals not related to you who we may contact
Name 1
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Name 2
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Demographic Information
Number of Siblings
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Mother’s name, occupation and current place of employment
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Father’s name, occupation and current place of employment
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Tell us why you want to pursue a health career (less than 500 words)-
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Name
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First
Last
In consideration of my scholarship application for the Greensboro Medical Society Foundation Scholarship, I hereby understand and agree that I have obtained the attached application on my own freewill, and such application has been provided to me with no written or implied conditions or special considerations. I hereby agree to indemnify and hold harmless the Greensboro Medical Society Foundation, its governing Board, and members from any and all liability pertaining to: (i) any inquiries related to my application; and (ii) whether my application is selected for a scholarship award. I affirm by my signature below that the above information is correct to the best of my knowledge. I further agree that if I am awarded a scholarship, and I do not take a prep course for entrance into healthcare professional school, I will contact the Greensboro Medical Society Foundation and the money will be immediately refunded by me to the Greensboro Medical Society Foundation, and I agree to repayment enforcement based upon North Carolina statutes. In addition, I acknowledge that I will allow members of the Greensboro Medical Society Foundation Scholarship Committee or Greensboro Medical Society Foundation to contact any references, past employers or educational institutions listed in this application
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