Franklin District Medical Society Medical Student Application Form

"Percy W. Wadman, M.D." Scholarship

Dear Applicant:

Thank you for your interest in the “Percy W. Wadman, M.D." Scholarship.  The following criteria must be met and/or submitted for you to be considered for this scholarship:

  • One or both parents or guardians must live in Franklin County.
  • A letter of matriculation must be submitted from your medical school.
  • A copy of the letter of recommendation from your undergraduate school to the medical school must be submitted.

Application Deadline: April 30

Your application is not considered complete until you email to csalas@mms.org a PDF of any other supportive documentation requirements that are listed above.

All applicants will be notified of the Society’s decision in writing.

All fields below are required. 

Applicant Information: 

First Name:*
   
Middle Name:*
   
Last Name:*
   
Mailing Address:*  
   
Legal Residence:*  
   
Phone Number:*
   
Email Address:*

Medical School:  

Full Name of School:*  
   
Address of School:*  
   
Graduation Year:*


Parent/Guardian Information:  

First Name:*
   
Middle Name:*
   
Last Name:*
   
Mailing Address:*  
   
Legal Residence:*  


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 Full Name):*  
   
Date:*

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