JF MEDICAL TEST FUND APPLICATION

SCHOLARSHIP APPLICATION FORM
PERSONAL DATA
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Place of Birth*
(City, State, Country)
Ethnicity*
Home Address*
Street address, City, State, Zip Code
Phone Number*

Area CodePhone Number
E-mail*
Upload Drivers License*

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Briefly describe any special circumstances or obligations you have that might demonstrate financial need.

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INSTITUTION INFORMATION
Name of Institution*
Address of Institution*
Admission Type*
Expected Graduation Date*

MonthDayYear
GPA*
Upload Transcripts*

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Upload Letter of Good Standing*

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TEST INFORMATION
Which exam will you be taking?*
Date of Examination*

MonthDayYear
Date
Upload Receipt of Exam Registration*

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DISCLOSURE
Elegibility Criteria: Applicant

1. Comes from a disadvantaged background as defined by the U.S. Department of Health and Human Services: An individual from a disadvantaged background is defined as one who comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary, HHS, for use in health professions and nursing programs.

2. Is Currently enrolled in a Miami-Dade County college/university, enrolled in a Miami- Dade County medical school, and/or be a Miami-Dade County resident enrolled in a college/university or medical school attempting to take the MCAT or USMLE exam.

3. Is currently in good academic standing.

4. Has above a 3.5 GPA. (Undergraduate Students Only)
I have read the above criteria and confirm I am eligible.*

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Attestation Statement:

I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
Signature

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SCHOLARSHIP APPLICATION FORM

PERSONAL DATA

INSTITUTION INFORMATION

TEST INFORMATION

DISCLOSURE