Dr. Leslie Mintz Scholarship Foundation

Dr. Leslie Mintz Scholarship Foundation
Please ensure you have all four required documents ready for upload before starting the application process. You will not be able to complete the application without the necessary documents.

The Dr. Leslie Mintz Scholarship has been awarded annually to an optometry school student or students who possess academic excellence, financial need, and the desire to serve the profession of optometry in New Jersey as did Dr. Leslie Mintz.

The primary intent of this Foundation is the furthering of education in the profession of optometry by making scholarships available to students of optometry.

The total number and dollar amount of scholarships awarded each year varies based upon the number of qualified applicants and the yearly performance of the scholarship endowment fund.

Applications and all supporting documents are due by January 15th

CRITERIA FOR CONSIDERATION:
1. Applicants must intend to practice in New Jersey.
2. Be engaged with local, state, or national organized optometry such as the New Jersey Society of Optometric Physicians, NJSOP Student organization (should your optometry school have one), American Optometric Student Association, etc.
3. Must have a current legal address in New Jersey OR previously resided in New Jersey within the past 10 years.
STOP - Please make sure you have all four required documents listed below prepared for upload before beginning the application process. You will not be able to complete the application without these documents, and there is no option to save your progress if you leave the application incomplete.

FOUR REQUIRED DOCUMENTS FOR UPLOAD

In addition to the application, you are required to upload the following documents:
1. A LETTER FROM THE FINANCIAL AID OFFICER IN YOUR SCHOOL WHICH DETAILS THE AMOUNT OF ALL FINANCIAL ASSISTANCE YOU HAVE RECEIVED AND THE FINANCIAL AID OFFICER’S RECOMMENDATION CONCERNING YOUR NEED
2. A PERSONAL AND/OR SCHOLASTIC RECOMMENDATION SUBMITTED BY ANY PERSON YOU CHOOSE
3. YOUR STATEMENT OF WHY YOU SHOULD BE SELECTED FOR THE DR. LESLIE MINTZ SCHOLARSHIP (which explains your New Jersey residency or intent to practice in New Jersey)
4. A COPY OF MOST RECENT OPTOMETRY SCHOOL TRANSCRIPTS
  (First-year students, please upload your most recent undergraduate transcripts.)
Finally, as this scholarship is named after a strong leader in organized optometry, it is the desire of the scholarship committee that recipients of this scholarship become the future leaders of the NJSOP. Our leaders develop through ongoing engagement in NJSOP committees, meetings, and local society events. We ask all recipients to contribute statements/testimony about their professional journey for scholarship promotion.
BIOGRAPHICAL INFORMATION
DATE*

MonthDayYear
Date
APPLICANTS NAME*

First NameLast Name
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL*
example@example.com
CELL #*
Please enter a valid phone number.Format: (000) 000-0000.
SCHOOL ADDRESS (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HomeSchool
DATE OF BIRTH*

MonthDayYear
Date
GENDER IDENTITY*
MaleFemale
MARITAL STATUS*
NUMBER OF DEPENDENTS*
NUMBER OF FAMILY MEMBERS (including self)*
NUMBER OF FAMILY MEMBERS IN COLLEGE (including self)*
HAVE YOU EVER BEEN A NJ RESIDENT?*
if so when

MonthDayYear
Date
CITY AND STATE WHERE YOU INTEND TO PRACTICE?*
OPTOMETRIC SCHOOL*
1234
CURRENT CUMULATIVE GPA IN OPTOMETRY SCHOOL (UNDERGRAD IF 1ST YEAR)*
OTHER COLLEGIATE INFORMATION
NAME, LOCATION OF SCHOOL*
YEARS IN ATTENDANCE*
DEGREE AWARDED*
NAME, LOCATION OF SCHOOL
YEARS IN ATTENDANCE
DEGREE AWARDED
OPTOMETRIC ORGANIZATIONS AND OFFICES*
COMMUNITY ORGANIZATIONS AND INTERESTS*
AOA Optometry’s MeetingAOA on Capitol HillAOA Affiliate ConnectionsAOSA Student MeetingNJSOP Student MeetingNJSOP Young OD/Student Social EventNJSOP Committee MeetingNJSOP Local Society MeetingOther State Optometry Society MeetingsOptometry School Organized Optometry Club MeetingNJSOP Volunteer at Therapy by the Sea, NJ Special Olympics, etc.Other
(please add details)
LEADERSHIP INVOLVEMENT WITHIN ORGANIZATION*
PLEASE LIST ANY ON OR OFF CAMPUS EMPLOYMENT YOU HAVE HELD IN OPTOMETRY SCHOOL*
SPECIAL OPTOMETRIC INTERESTS*
FOUR REQUIRED DOCUMENTS FOR UPLOAD
A LETTER FROM THE FINANCIAL AID OFFICER IN YOUR SCHOOL WHICH DETAILS THE AMOUNT OF ALL FINANCIAL ASSISTANCE YOU HAVE RECEIVED AND THE FINANCIAL AID OFFICER’S RECOMMENDATION CONCERNING YOUR NEED*

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A PERSONAL AND/OR SCHOLASTIC RECOMMENDATION SUBMITTED BY ANY PERSON YOU CHOOSE*

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YOUR STATEMENT OF WHY YOU SHOULD BE SELECTED FOR THE DR. LESLIE MINTZ SCHOLARSHIP (which explains your New Jersey residency or intent to practice in New Jersey)*

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A COPY OF MOST RECENT OPTOMETRY SCHOOL TRANSCRIPTS (First-year students, please upload your most recent undergraduate transcripts.)*

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FINANCIAL INFORMATION

STUDENT EXPENSES*

Rows	LAST ACADEMIC YEAR	ANTICIPATED THIS ACADEMIC YEAR
TUITION AND FEES
BOOKS/SUPPLIES/EQUIPMENT
LIVING EXPENSES (including rent/mortgage)
TRANSPORTATION
HEALTH RELATED EXPENSES
MISCELLANEOUS

STUDENT INCOME*

Rows	LAST ACADEMIC YEAR	ANTICIPATED THIS ACADEMIC YEAR
AID FROM STUDENT'S PARENTS
STUDENT'S WAGES AFTER TAXES
SPOUSE'S WAGES AFTER TAXES
OTHER INCOME
GRANTS/SCHOLARSHIPS
LOANS

ALL BANK ACCOUNT BALANCES*
OTHER INVESTMENTS/ASSETS*
TOTAL STUDENT LOAN INDEBTEDNESS*
(include undergraduate and current year loans)
OTHER INDEBTEDNESS*
please explain
YESNO
YESNO
PARENT NAME*

First NameLast Name
PARENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT NAME*

First NameLast Name
PARENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
* Please refer to our Website Privacy Policy

on our website, www.njsop.org regarding the use of information provided in this application.

STUDENT’S CERTIFICATION AND AUTHORIZATION

I DECLARE THAT THE INFORMATION REPORTED ON THIS FORM, TO THE BEST OF MY KNOWLEDGE, IS ACCURATE AND COMPLETE. I FURTHER AGREE TO PROVIDE ANY OTHER OFFICIAL DOCUMENTATION NECESSARY TO VERIFY INFORMATION REPORTED ON THE STUDENT FINANCIAL STATEMENT.
Signature*

Clear
Should be Empty:

Dr. Leslie Mintz Scholarship Foundation

BIOGRAPHICAL INFORMATION

OTHER COLLEGIATE INFORMATION

FINANCIAL INFORMATION