1.

Faculty Reference
Please supply contact information for a faculty member at your medical school or undergraduate school, who will submit a letter of reference in support of your application. This faculty member must be different from your Home Institution Faculty Sponsor, whose contact information you provided in the application qualifier.

Institution:

Title:

First Name:

Last Name:

Address:

City:

State:

Postal Code:

Telephone:

Fax:

Email:

2.

Enrollment Certification Letter
Your application will not be complete until a letter from your medical school has been received, confirming that you are enrolled in medical school, that you will have completed one year of training as of June 2005, and that you are a student in good standing. This letter may be submitted by the Dean of Students, Dean of Student Affairs, Registrar, Dean of Academic Affairs, or other appropriate person.

NOTE: If the same individual will be submitting both a letter of reference and your enrollment certification, please insert the contact information in both above and below.

Institution:

3.

Will you have completed at least one year of study in a school of medicine or osteopathy, prior to June 2006?

4.

Are you a citizen, non-citizen national, or permanent resident alien of the United States?

5.

Country of Citizenship:

6.

Home Institution Faculty Sponsor
Applicants must have a designated Faculty Sponsor at their home medical school, who has expertise in geriatrics or gerontology. The Sponsor will support the student's application, and will act as an advisor to the student in his/her ongoing geriatrics education and research activities. Faculty Sponsors must submit a plan outlining how they will work with the student throughout his/her medical school training. Please provide your faculty sponsor's contact information here:

Institution:

7.

Your Email Address:

8.

How did you learn about this scholarship program?

9.

Personal Information

Title:

10.

Permanent Address (if different from above)

Address:

11.

Date of Birth:

12.

MO / MD / MD PhD anticipated in:

13.

Graduate or Professional School that You Are Currently Attending:

Institution:

14.

Previous Graduate or Professional Schools Attended:
(begin with your most recent)

Dates of Attendance

From:

To:

Major:

Degree GPA:

Institution #2:

Dates of Attendance

From:

To:

Major:

Degree GPA:

Institution #3:

Dates of Attendance

From:

To:

Major:

Degree GPA:

15.

Undergraduate Schools Attended:
(begin with your most recent)

Institution #1:

Dates of Attendance
(month and year are both required)

From:

To:

Major:

Degree GPA:

Institution #2:

Dates of Attendance
(month and year are both required)

From:

To:

Major:

Degree GPA:

Institution #3:

Dates of Attendance
(month and year are both required)

From:

To:

Major:

Degree GPA:

Institution #4:

Dates of Attendance
(month and year are both required)

From:

To:

Major:

Degree GPA:

16.

Honors and Awards in Undergraduate / Graduate Schools:

17.

Extracurricular, Community, and Avocation Activities:

18.

Courses, Research Projects, or Other Experiences in Geriatrics / Gerontology:

19.

Please provide a personal statement describing your career goals, research interests, your reasons for being interested in this scholarship program, and other objectives you have for the scholarship, in the context of your career goals as you currently perceive them. If you are remaining at your own institution, please include a brief summary of your research topic and plan. Former recipients of this award who are reapplying must provide information on the scholarship they already received:

20.

I currently attend:

21.

Answer this question only if you selected a) in question 20.

If you currently attend one of the institutions listed in 20a), you may elect to remain at your own school to conduct your research project and clinical and didactic training. I would like to:

22.

Answer this question only if you selected b) in question 20 OR if you selected b) in question 21.

If you apply to travel to a National Training Center, please list the area(s) of research you are interested in:

23.

Answer this question only if you selected b) in question 20 OR if you selected b) in question 21.

Indicate, in preferred order, the top three geographic areas to which you would be willing to travel to attend a national training center:

(PLEASE NOTE: For students applying to a National Training Center, travel and housing expenses are not included in the scholarship. It is possible that some or all of the Training Centers will have additional funds to assist students with these expenses, but this will not be known until after the February 7, 2005, application deadline. It is also possible that not all of the regions listed below will have a Training Center. The Training Centers will be announced in April or May 2005.)

a) First choice:
b) Second choice:
c) Third choice:

24.

Faculty Reference

I understand that my application will not be considered complete until I obtain a letter of reference from a medical or undergraduate school faculty member.

25.

Enrollment Certification

I understand that my application will not be considered complete until I obtain a letter from my medical school certifying that I am a currently enrolled student in good standing, who will have completed one year of medical school by June 2005.

26.

Faculty Sponsor

I understand that my application will not be considered complete until it includes a Faculty Sponsor plan and NIA-style biographical sketch.

27.

Applicant Agreement

I understand that all of the information that I have provided will be verified as a normal part of the application process and that any application which contains falsehoods will be immediately disqualified, and my institution notified of the irregularities.

I certify that, to the best of my knowledge and belief, all of my statements made in this application and to persons who contact me about this application, are true and made in good faith.