Scholarship - Newcomers Financial Support Program Application

Newcomer Financial Support Program Application Form

Whitetulip Health Foundation

section - if member
Are you a member of Whitetulip Health Foundation *

Yes No

section - Informations to fill
APPLICANT INFORMATION
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *
Current Address: *

Street Address

Street Address Line 2

City State

Zip Code
Gender

Female Male
Social Status *

Single Married
Nationality *
U.S. Citizen *

Yes No
Visa Type (e.g. J1) *
Immigration Status *
Arrival Date to USA *

Month Day Year
Date
Ethnic Origin

American Indian African American Caucasian Asian/Pacific Islander Spanish Surname/Hispanic Other (please write)
ACADEMIC INFORMATION
Graduated Medical Institution: *
Graduation Date *
Graduation Date (Month &Year): *
Which exams you have taken?

USMLE - Step 1 USMLE - Step 2 CK USMLE - Step 2 CS TOEFL
USMLE Step 1 Score *
USMLE Step 2 CK Score *
USMLE Step 2 CS Score *
TOEFL *
Other Exams
GPA

CURRENT and PAST POSITIONS *

	Position	Institution / City	Dates
1
2
3
4
5

EXPENSES
Please list the amount of assistance needed for the educational activity you are applying for? (Write the cost of each item approximately and multiply with the number of months if it is recurring)

EXPENSES LIST *

	Amount of Assistance Needed
Tuition
Accommodation
Exam Fee
Application Fee (Residency / Fellowship etc.)
Transportation
Phone - Internet
Grocery and Other Living Expenses
Health Insurance
Total

OTHER FINANCIAL RESOURCES YOU HAVE *
Please be as specific as possible
BRIEF EXPLANATION FOR CONSIDERATION *
The Scholarship Selection Committee gives careful consideration to the financial needs of applicants, as well as academic achievement and future goals. Explain why you need this assistance and should be considered for this scholarship.
Are you relative to any member of Whitetulip Health Foundation Board or any member of Selection Committee *

Yes No
Please identify the Board member and relationship *
REQUIRED DOCUMENTS *

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Cancel of
- Up-to-date CV
- A recent photo obtained in the last 6 months
- A copy of the diploma (or proof of studentship) from medical school or other healthcare institution in another country.
- A proof of initiation to continue a medical career in the US such as proof of ECFMG account for medical doctors or its equivalent according to the applicant’s medical profession to indicate the initiation of the US medical credentialing process.
- The copy of the receipt of the application for permanent legal status in the USA.
- Copy of the document that shows current visa-residency status and entry date of USA.
- Most recent I-94 document.
- Whitetulip Health Foundation membership verification letter.
SIGNATURES

I, the applicant, certify that the information in this application is complete and correct to the best of my knowledge and in the event I am awarded a scholarship, all funds will be used to further my medical education and or career.
Signature of Applicant *

Clear
Today's Date *

Month Day Year
WE RESPECT YOUR PRIVATE, SENSITIVE, AND CONFIDENTIAL INFORMATION

All your private, sensitive, and confidential information received by Whitetulip Health Foundation will only be used to evaluate and process your scholarship application. We exercise extreme care and discretion when handling such information. Your personal information, in any circumstances, will not be shared with other individuals or organizations without your permission.

BEWARE OF SCAMMERS!

Whitetulip Health Foundation does not initiate contact with our members, volunteers, and/or applicants by email, text messages or social media channels to request their personal, sensitive, confidential, or financial information, including requests for SSN, passwords, or access information for credit cards, banks or other financial accounts.

If you receive such a request this might be a scam! Please contact us immediately.
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Newcomer Financial Support Program Application Form

APPLICANT INFORMATION

ACADEMIC INFORMATION

SIGNATURES