Primary Care Scholarship Program

Section A: Personal Information

Last Name

First Name

Current Address

Street Address

Address Line 2

If Needed

City

State/Province/Region

ZIP/Postal Code

Country

Phone Number

Effective Date of Indiana Residency

mm/dd/yyyy

Section B: Community Background

In the following section, enter the communities (up to four, if appropriate) in which you have lived the longest. Indicate the number of years you resided in each community (rounded to the nearest whole year). Include the community size by using one of the community designations below.

Small town (population less than 2,500)
Small city (2,500 to 20,000)
Medium-size city (20,000 to 50,000 including suburbs)
Large city (50,000 to 250,000 including suburbs)
Major metropolis (over 250,000 including suburbs)

First Community

Residence

City, County, State

Duration

Community Size

Are there any additional communities you'd like to include?

Yes

Section C: Primary Care Commitment

Have you applied or made a commitment to receive any funding that requires you to practice primary care in the state of Indiana or elsewhere?

Yes

Section D: Personal Statement and Letters of Recommendation

In the File Upload field, please attach a personal statement that explains why you are choosing to enter a primary care specialty. Include any previous community service experience that has had an impact on your decision to become a primary care physician. Also, include your professional goals and the special strengths you believe you may bring to a primary care specialty profession.

The Selection Committee requires that the applicant provide at least two letters of recommendation. One recommendation may be from a physician who knows of your interests and career goals. The second recommendation may be from someone who knows you well enough that also knows of your interest and career goals. Both recommendations should also address your relevant employment, commitment to primary care, community service, character skills, and involvement in serving others.

Please attach all letters of recommendation below.

Recommenders

File Upload

Please attach your personal statement and letters of recommendation.

Drop your files here

Section E: Certification Statement

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief.

For any questions, please contact the Student Financial Services Office at medaid@iu.edu.

Send me a copy of my responses

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