MMET Scholarship Fund | Maine Medical Association

Full Name *

SSN #

Mailing Address *

City *

State *

Zip Code *

Legal Address *

# Years at Legal Residence *

Phone Number *

Email Address *

Date of Birth *

Place of Birth *

Parent's Names *

Parent's Occupations *

Address(es) *

Pre-medical School *

Graduation Date *

GPA *

Present Medical School *

When did/will you enter medical school? *

When do you expect to receive your M.D. or D.O. degree? *

Have you attended any other medical or medically-related schools? *

If so, when and where?

What specialty, if any, have you selected or do you intend to select?

Where do you think you might like to practice? *

Please tell us something about yourself, to include extracurricular activities. *

Application Certification: I believe I am eligible for a scholarship from the Maine Medical Education Trust. I certify that all statements made on this application are to the best of my knowledge complete and accurate. *

Yes

No

Are you applying to the Maine Medical Education Loan Program (through FAME)? (If NO, please continue with Finances Section) *

Yes

No

Applicant's total annual income as reported on income tax return

Parent's or Partners/Spouses total annual income as reported on tax return (Put 0 if NA)

Total Combined Income

Estimate of Total Combined Income (from Part 1) to be applied to annual college-related costs of applicant, if $-0-, please explain

Gifts, grants, scholarships, tuition assistance to be received

Other available resources including federal/state/other loans

Total Resources to be used toward College Expenses

Applicant's tuition fees

Applicant's books and supplies

Applicant's living situation (check one)

College Room and Board

Off-Campus Housing

Living at Home

Related costs associated with living situation selected above:

Other household members' annual college-related costs (Put 0 if none)

Current annual college loan payments for household members

Total College-Related Expenses for applicant and family

Available Resources Less College Related Expenses

Financial Information Certification: I certify that all financial information on this application is to the best of my knowledge complete and accurate.

Yes

No

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