ACMC'S ANNUAL MEDICAL STUDENT SCHOLARSHIP APPLICATION FORM

Return completed application form and two letters of reference by June 15, 2012 to:
Kari Bredberg
Physician Recruitment & Scholarships
Affiliated Community Medical Centers
101 Willmar Avenue SW, Willmar, MN 56201

1 Name:

2. Present address:

3. Present phone:

5. Permanent phone:

6. Email:

7. Birth date:

8. High school attended:

Graduation date:

9. College attended:

Graduation date:

10. College major:

11. Medical school attending:

Medical school address:

12. Anticipated year of graduation:

13. Anticipated residency specialty:

14. Geographic location you plan on working in upon completion of your residency:

15. Marital status:

Spouse/Significant other's occupation:

16. On a separate, attached page, please describe why you believe yourself to be a deserving candidate for this scholarship.

Signature of applicant:

Date: