Berkshire District Renewal Application for Revolving Scholarship Loan

Instructions:

  1. Complete Parts I, II, and III of this application.
  2. Attach (or have mailed by April 10) reference letter from Dean of Medical School.
  3. Submit application by April 15 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

Required fields are marked with an *


 Part I. Applicant Information

I*,  , a resident of Berkshire County Massachusetts, do hereby apply for renewal of the Berkshire District Medical Society Scholarship Loan for the academic year of *  . 

 

First Name:*
   
Last Name:*
   
Age:*
   
Gender:*
   
Home Address:*  
   
Cell Phone Number:*
   
Email Address:*
   
Marital Status of Applicant:*
  

Have you been accepted to continue your studies next year?*
  

Is continuing medical school contingent upon obtaining this scholarship?*
  

Have you applied, or do you expect to apply, elsewhere for a scholarship for the same period?* 
  

In the event you are not granted this renewal, what other plans do you have for continuing your education?*

   


Part II. Educational Progress

 
Present Medical School:* 

Reference to be received by Medical Society by April 10 from Dean of
Medical School:*

 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 to which I have been accepted will be paid by the Berkshire District Medical Society up to the amount of $5,000 per year renewable for additional school years.  I further understand that the Committee on Scholarships of the Berkshire District Medical Society shall follow my progress in medical school with interest and retain the right to re-evaluate the continuance of the scholarship loan yearly.
 
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 to the Berkshire District Medical Society Fund for Medical Scholarships.  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.
 
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 have provided is true to the best of my knowledge. 

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

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