FOR SCHOOL USE ONLY

C ITY D OCTORS scholarship

Entering Class: Scholarship:

APPLICATION FOR CITYDOCTORS NYC SCHOLARSHIP

Student Information
1. Name: 2. Student ID Number: 4. Permanent address: 5. Mailing address: 6. Phone number: 8. Country(s) of citizenship: 7. Email: 9. Country(s) of legal residence: 3. Date of Birth: (mm/dd/yyyy) / /

10. Please list all languages, including English, you are fluent in:

Student Qualification
To qualify for the CityDoctors NYC Scholarship, you must be a US citizen or permanent resident and have a permanent address in New York City*. In addition, an applicant must fulfill one of the following criteria and provide physical verification. PLEASE CHECK ALL THAT APPLY I am presently and have been a resident of New York City* for the past five years I am a graduate of a New York City high school I am a full-time employee for either the City of New York or the Health and Hospital Corporation At least one of my parents is a full time employee for either the City of New York or the Health and Hospitals Corporation
*Manhattan, Queens, Brooklyn, The Bronx, and Staten Island

I understand that by applying for the CityDoctors NYC Scholarship I am also giving St. Georges University my permission to share financial and academic information gathered as part of my application for admission and this scholarship with the Health and Hospitals Corporation.

Signature:

Date:

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Application Instructions
1. Write an essay that explains your professional goals as a primary care physician and your commitment to post residency service at a Health and Hospitals Corporation (HHC) affiliated hospital. Submit your essay on a separate sheet and enclose it with this application. 2. Complete all questions that apply to you and your family on this application. All students, whether independent and regardless of age, must supply information and documentation about themselves and their families. Failure to complete all questions will result in an incomplete status. 3. All students applying to the CityDoctors NYC Scholarship program must fill out a Free Application for Federal Student Aid (FAFSA) and include financial information for both student and parent. Further documentation may be requested. 4. Include documentation which supports that you meet the selection criteria (i.e. copy of high school diploma, pay stub, residency affidavit, etc.) 5. You must print and sign the agreement on page 1 and the certification and authorization on page 5. You can either mail, fax, or scan and email the completed application and required documents. RETURN APPLICATION AND REQUIRED DOCUMENTS TO: St. Georges University Tel: (800) 899-6337 or (631) 665-8500 c/o The North American Correspondent Fax: (631) 666-8623 University Support Services, LLC Email: jcampbell@sgu.edu ATTN: Jennifer Campbell 3500 Sunrise Highway, Building 300 Great River, NY 11739

Selection Process
To qualify for the CityDoctors NYC Scholarship, in addition to having a permanent New York City address and to being a US citizen or permanent resident, an applicant must fulfill one of the following criteria and provide physical verification. 1. Be a resident of New York City for the past five years. 2. Be a graduate of a New York City high school. 3. Be a full-time employee for either the City of New York or HHC. 4. Have at least one parent who is a full-time employee for either the City of New York or HHC. You should be aware that due to limited funding and the quality of the applicants, the scholarship program is generally very competitive. Unfortunately, awards cannot be made to every deserving student. Award determinations are based on: (1) Demonstrated academic excellence and other sources, (2) The applicants commitment to the special qualities associated with each program, and (3) The degree of the familys financial need and the availability of funds from the school.

Students Commitment and Expectations

In return for accepting the scholarship: 1. Students will commit to an attending position in primary care at one of HHCs hospitals for the amount of years the scholarship was provided (four years for a full scholarship; two years for a half scholarship). This commitment can be fulfilled at any HHC hospital. 2. If for some reason the student is unable to fulfill this commitment, the scholarship will convert to a loan. 3. Students will sign an agreement to the terms of the convertible loan when they accept the scholarship. 4. Students must maintain the regular academic standards set forth by St. Georges University School of Medicine.

Application Deadlines and Award Notification

Applications will be accepted from either applicants or accepted students. Applications will receive either an award letter or a letter of declination in a timely manner. DEADLINES: November 1 for class commencing in January June 1 for class commencing in August Late applications will be reviewed up to the day of registration for students with extenuating circumstances, including being accepted to the University after the scholarship deadline. No application will be accepted later than the first day of classes.
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Student Information
1. Marital Status: 2. During the past year: a. How did you support yourself? b. How much money did you earn? c. What was your occupation? d. How much money did your spouse earn? e. What was your spouses occupation? 3. List the types and amounts of outstanding educational and commercial debt you have already incurred and the amount of unpaid balance. Type of Loans Unpaid Balance

4. Have you ever declared bankruptcy or defaulted on a loan?

YES

NO

5. What scholarships did you receive as an undergraduate and/or graduate student? 6. Do you and/or your spouse own a home? a. What year was it purchased? b. What was original purchase price? US$ 7. Please list the value of your assets. a. Land and other buildings (other than home) b. Annual income produced c. Savings d. Money owed to by others e. Other assets: (explain) 7. Do you own an automobile? YES NO (If yes, complete a and b for each automobile.) b. Year of manufacture b. Year of manufacture US$ US$ US$ US$ YES NO (if yes, complete ad below) c. How much do you still owe on the purchase value? US$ d. What is present market value? US$
Value Description

a. Make (VW, Fiat, Toyota, Ford, etc.) a. Make (VW, Fiat, Toyota, Ford, etc.)

8. List agencies/foundations/governments to which you are applying for financial aid, excluding St. Georges University. Agency/Foundation/Government Application date Award notification date Expected Amount US$

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Parents Information
1. What is parents current marital status? Married Father living/Mother deceased Separated/Divorced Mother living/Father deceased

2. Fathers name: a. Address: b. Occupation/Title: c. Employer: d. Number of years with employer: e. Annual income:

3. Mothers name: a. Address: b. Occupation/Title: c. Employer: d. Number of years with employer: e. Annual income:

4. How many persons, including yourself, depend on the income of your parents for daily living expenses? List your family members (do not include yourself) Name of Family Member Age Relationship to You Occupation or School Tuition/Fees Room and Board Amount of Parents Contribution Scholarship and Gift Aid

5. During the past year, JanuaryDecember, describe your parents income sources: a. Fathers work: b. Mothers work: c. Your work: d. Spouses work: US$ US$ US$ US$ e. Family business f. Family real estate holdings g. Pension/Annuity/Retirement h. Other household members US$ US$ US$ US$ NO i. Interest/Dividend j. Government Assistance k. Other US$ US$ US$

6. Do your parents own their own home? a. What year was it purchased?

YES (If yes, complete ad below)

c. How much do you still owe on the purchase value? US$ d. What is present market value? US$
Value Description

b. What was original purchase price? US$ 7. Please list the value of your parents assets (if applicable) a. Land and other buildings (other than home) b. Annual income produced c. Savings d. Money owed to by others e. Other assets: (explain) 8. Do your parents own an automobile? YES NO

US$ US$ US$ US$

(If yes, complete a and b for each automobile.) b. Year of manufacture b. Year of manufacture
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a. Make (VW, Fiat, Toyota, Ford, etc.) a. Make (VW, Fiat, Toyota, Ford, etc.)

CERTIFICATION AND AUTHORIZATION

We declare that the information on this form is true, correct, and complete. St. Georges University School of Medicine has our permission to verify the information reported by obtaining documentation as needed. WARNING: Providing false information may result in the University revoking its initial decision to enroll this student.

Student Signature

DATE:

Spouses Signature

DATE:

Fathers Signature

DATE:

Mothers Signature

DATE:

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