AHC Scholarship Application

AFRICAN HERITAGE CAUCUS OF AAPA 2017 SCHOLARSHIP APPLICATION

 

Part 1 – Personal Information

First Name ____________________________________________________________________

Middle Name __________________________________________________________________

Last Name _____________________________________________________________________

Home Address _________________________________________________________________

Email ___________________________________________________________________________

 

PA Program Name _____________________________________________________________

Address _________________________________________________________________________

City _____________________________

State ____________________________

Zip Code ________________________

 

Graduation date _________________________________________________

 

Part 2 – References/ Letter of Support (Please provide your references with the attachments at the end of this application to complete and submit via email)

Name ______________________  Title ______________Contact Number____________

Name _______________________Title ______________Contact Number____________

 

Part 3 – PA Program Director

I attest that  ___________________________________________________ is a student at our institution and is in good academic standing.

 

PA program director name _____________________________________________

PA program director signature _________________________________________

Date _______________________________________________________________________

 

Part 4 – African Heritage Caucus Membership

ALL ELIGIBLE STUDENT SCHOLARSHIP APPLICANTS HAVE TO BE A MEMBER OF THE AFRICAN HERITAGE CAUCUS. PLEASE BE SURE TO PAY FOR YOUR MEMBERSHIP DUES ONLINE HERE .

 

 

 

Part 5 – Community Service

Describe your involvement in community activities that will enhance your career as a PA. (100 words or less)

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Part 6 – Describe the impact of receiving the AHC scholarship.

 

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Part 7 – Photograph

Please include a headshot or passport-type photograph of yourself as an electronic attachment with your application.

 

Part 8 – Signature of applicant

By signing below, I attest that all information in this application is true and accurate to the best of my knowledge. I also agree if I receive the scholarship, my photo and information may be published in AAAPA or AHC literature. My application will not be considered complete until the application and supporting documentations are received at aapaahc@gmail.com .

 

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AHC 2017 SCHOLARSHIP APPLICATION

REFERENCE/ LETTER OF SUPPORT

 

Name of Applicant _____________________________________________________________

Reference Name/ Title ________________________________________________________

Contact Information (email vs phone) _______________________________________

 

Describe the attributes and qualities of the applicant that makes you believe that he/she will continue to foster knowledge and philanthropy that enhances quality and addresses disparities in healthcare. Please email response to: aapaahc@gmail.com by the deadline: FEBRUARY 20, 2017. Please use the email subject “AHC Scholarship Application 2017.”

 

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AHC 2017 SCHOLARSHIP APPLICATION

REFERENCE/ LETTER OF SUPPORT

 

Name of Applicant _____________________________________________________________

Reference Name/ Title ________________________________________________________

Contact Information (email vs phone) _______________________________________

 

Describe the attributes and qualities of the applicant that makes you believe that he/she will continue to foster knowledge and philanthropy that enhances quality and addresses disparities in healthcare. Please email response to: aapaahc@gmail.com by the deadline: FEBRUARY 20, 2017. Please use the email subject “AHC Scholarship Application 2017.”

 

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