Berkshire District New Application for Revolving Scholarship Loan

Instructions: 

Application should be filed as early as possible.  No application can be considered unless completely filled out and all of the materials are filed by April 15.

  1. Complete Parts I, II, and III of this application.
  2. Submit a 2” x 2” photo for identification purposes.
  3. Submit a statement of 500 words or less on your concept of medicine and motivation to attend medical school and enter the medical profession.
  4. Submit four references or have them mailed by April 15. 
    1. One from guidance counselor in college
    2. One from applicant’s major department chairman in college
    3. One each from two non-medical professional persons in the applicant’s community.
     
  5. Submit by April 15 a transcript of college academic record to the Berkshire District Medical Society, c/o Susan Poulin, 20 Walnut Street, Pittsfield, MA  01201 Attention: Scholarship Committee
Your application is not considered complete until you email to spoulin@berkshire.rr.com a PDF of any other supportive documentation that is a requirement on the application.

Application Deadline: April 15

You will be notified of our decision regarding this application in September. 

Required field are marked with an *


 Part I. Applicant Information

I*,  , a resident of Berkshire County Massachusetts, do hereby apply for consideration as a recipient of the Berkshire District medical Society Scholarship Loan for the academic year of * 

First Name*:
   
Middle Name*:
   
Last Name*:
   
Gender*:
   
Age*:
   
Place of Birth: (city, state)*
   
Date of Birth*:
   
Present Address*:  
   
Cell Phone Number*:
   
Email Address*:
   
List past home addresses*:
(For past 10 years)
 
   
Are you a citizen?*
                    
       
Do you have brothers?*
  
 
  If yes, what are their ages:     
     
Do you have sisters?*
  
 
  If yes, what are their ages:   

Information about Parent/Guardian 1:

Parent/Guardian 1 Name*:
   
Address*:
   
Occupation*:
   
Age*:
   
Taxable Income- This Year*:  
(From Federal Income Tax Form)
   
Taxable Income-Last Year*:   
(From Federal Income Tax Form)
   
State of Health*:

Information about Parent/Guardian 2: 
 
Parent/Guardian 2 Name:
   
Address:
   
Occupation:
   
Age:
   
Taxable Income-This Year:   
(From Federal Income Tax Form)
   
Taxable Income-Last Year:   
(From Federal Income Tax Form)
   
State of Health:

Applicant's Income: 
 
Taxable Income -This Year*:
   
Taxable Income -Last Year*:
   
Marital Status* 
  
  (If married, fill out spouse income)
Spouse's Income-This Year:
   
Spouse's Income-Last Year:
   
Number of Children & ages:  
   
To what medical school(s) have you applied?*  
   
To what medical school(s)
 have you been accepted?*
 
   
Which one will you attend?
   
Tuition amount:
If not accepted yet, when you are accepted, please notify us at once. 
 
If the event you are not granted this scholarship loan, what other plans do you have for your future education?* 

 

Have you applied or do you expect to apply elsewhere for financial aid for the same period? And if so, where?*

   


Part II. Educational History

Senior High School:*
   
Period of Study:*
(Give Dates)
   
College:*
   
Degree:*
Present College Status:*
  

 Part III. 

I understand that, if granted the Medical Scholarship Loan of the Berkshire District Medical Society, my tuition to an approved American or Canadian medical school or osteopathic medicine school to which I have been accepted and will attend will be paid by the Berkshire District Medical Society up to the amount of $5,000 per year renewable annually for additional school years.  This loan is at zero percent interest.  I further understand that my progress in medical school will be reviewed by the scholarship committee which retains the right to re-evaluate my continuance of the scholarship loan.

In accepting this scholarship loan, I agree to prepare myself for the practice of general medicine or one of its specialties (this does not exclude academic medicine and/or research as a goal) following graduation from medical school.  In the selection of my post graduate education, I will consider the approved programs of Berkshire County hospitals.

In realization of the fact that this scholarship loan will have afforded me an opportunity to enter the profession of medicine, I agree, the year of graduation from medical school, to start repayment of a minimum of $100.00 per month to the Berkshire District Medical Society Fund for Medical Scholarships.  One-half of the amount loaned should be repaid in four years and the balance in two additional years.  If, for any reason, I am unable to complete medical school, I promise to repay the scholarship loan within two years.  The funds that are returned to the Medical Society are used to support scholarship loans for new applicants.

I certify that all of the enclosed statements are true to the best of my knowledge.

I acknowledge that my digital signature below shall have the same force and effect as a written signature and intend to be bound by it, and I certify that all of the information I’ve provided is true to the best of my knowledge.

Electronic Signature (Please Type Full Name)*
   
Date*:

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