Equity in Education Stipend

Equity in Education Stipend

First Name

Middle Initial

Last Name

Date of Birth

Home Phone

Cell Phone

Email Address

Current Medical School

Entering your final year of Medical School

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Planning to apply for residency in General Surgery

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Do you require transportation during rotation

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Are you the first in your family to attend college

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Gender

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Racial/Ethnic Background

African American / Black

Filipino

Hispanic/Latinx

Hmong

Native American/Alaskan American

Native Hawaiian/Other Pacific Islander

Vietnamese

Resume/Curriculum Vitae

Personal Statement/response to three questions

Medical School Transcript

USMLE Score Report

File Upload

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Send me a copy of my responses

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