Jeff Lurey Independent Community Pharmacy Scholarship Application Form

Read and answer each question carefully prior to submitting your application. The winner will be notified on or before the 1st of May, 2023. Applcations must be received no later than the 1st of March, 2023.
The Jeff Lurey Independent Community Pharmacy Student Scholarship is awarded annually to a P3 student who has expressed an interest in independent pharmacy ownership. Applictions are reviewed by the Executive Committee of the Academy of Independent Pharmacy (AIP). Final selection is determined by vote of the entire Board of Directors of AIP. You must be a current GPhA Student Member to qualify. In addition to the $5,000 scholarship, the winner will receive invaluable support from AIP, AIP members, and AIP partners to help them achieve their dream of independent pharmacy ownership.
I. Personal Data:

Please tell us about yourself
Full Name*

First NameLast Name
Birthdate:*

MonthDayYear
Mobile No. :*

Area CodePhone Number
E-mail :*
Where the confirmation will be send to
Home Address :*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Optional Informations : Information regarding gender, ethnic origin and race are optional. The information is requested for post-scholarship report generation only and in no way affects your selection for this award.
Gender:

MaleFemale
Are you a US citizen?

YesNo
Race?

WhiteBlack of African AmericanHispanicAsianAmerican Indian or Alaskan, Native Hawaiian, or Pacific IslanderOther
Please check veteran status (Check all that apply)

VeteranSpouse of a VeteranNone of the Above
Current Status

I am a P3 Student Pharmacist at MercerI am a P3 Student Pharmacist at PCOMI am a 2nd Year Student Pharmacist at SouthI am a P3 Student Pharmacist at UGA
My graduation date is:
GPhA membership

Yes, I am currently a member of GPhANo, I am not currently a member of GPhA
Current GPA:
Activities, community activities, volunteer work, honors, offices held:
II. Current Career and Future Plans

Please tell us some information about your present history and career objectives. Your answers will help us to get to know you better. Family ownership of a pharmacy is not a requirement
Major Area of Interest:
Have you worked in an independent pharmacy in the past?

YesNo
Please describe your role in that independent pharmacy.

0/500
Do you have a family member or close relative that currently owns or manages an independent pharmacy

YesNo
If you have a family member that owns or manages an independent pharmacy, please tell us more about that relationship. (parent, grandparent, other family member, and your role, if any, in that pharmacy, etc.

0/500
Why do you want to own an independent pharmacy? (500 words maximum)

0/500
Do you plan to own an independent pharmacy in Georgia?

YesNo
What is your plan towards eventual ownership of an independent pharmacy? (500 words maximum

0/500
Have you taken any classes or received any degrees related to business management or entrepreneurial development

YesNo
If so, please describe the classes taken or degrees received below:

0/500
III. The Scholarship

Please answer the following questions related to the Scholarship. AIP administers many scholarships designed to offer aid to students that represent unique characteristics. Please check each of the qualifiers below that apply to you. Please note, if you are chosen to receive the scholarship, you may be asked to produce documentation verifying your unique eligibility.
If chosen to receive the Jeff Lurey Independent Community Pharmacy Student Scholarship what will you use the $5,000 for? (500 words maximum)

0/500
If chosen to receive the Jeff Lurey Independent Community Pharmacy Student Scholarship how will this help you? (500 words maximum)

0/500
If chosen, I can attend the annual GPhA Convention to appear on stage June 8th or 9th to receive the award

YesNo
IV. Other
Have you received other scholarships or financial support

YesNo
Have you attended a Georgia Pharmacy Convention

YesNo
Have you attended a Region Meeting

YesNo
If you have received other scholarships or financial support, what is the total amount of funding you have received or will have received upon your graduation.
Is there anything else you would like us to know about you? (500 words maximum)

0/500
V. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature:*
AIP is committed to equal opportunity in employment and education. AIP does not discriminate in any program or activity on the basis of race, color, religion, gender, age, national origin, disability, marital status, or any other protected class.
Should be Empty:

I. Personal Data:

II. Current Career and Future Plans

III. The Scholarship

IV. Other

V. Applicant's E-Signature