Indiana Primary Care Scholarship Program

Section A: Personal Information

Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darrussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote dIvoire Croatia Cuba Curaqao Cyprus Czech Republic Denmark Djibouti Dominica Dominica Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini - Swaziland Ethiopia Falkland Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guemsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay US Minor Outlying Islands Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Virgin Islands US Wallis and Futuna Western Sahara Yeman Zambia Zimbabwe Phone Number * Effective Date of Indiana Residency

Section B: Community Background

In the following section, enter the communities (A through D, if appropriate) in which you have lived the longest. Indicate the number of years you resided in each community (rounded to the nearest whole year). Include the community size by using one of the community designations (use the number) below.

1. Small town (population less than 2,500)
2. Small city (2,500 to 20,000)
3. Medium-size city (20,000 to 50,000 including suburbs)
4. Large city (50,000 to 250,000 including suburbs)
5. Major metropolis (over 250,000 including suburbs)

Sub-Section A

Residence City, County, State Duration Community Size

Sub-Section B

Residence City, County, State Duration Community Size

Sub-Section C

Residence City, County, State Duration Community Size

Sub-Section D

Residence City, County, State Duration Community Size

Section C: Primary Care Commitment and Personal Statement

Enclose a personal statement that explains why you are choosing to enter a primary care specialty. Include any previous community service experience that has had an impact on your decision to become a primary care physician. Also, include your professional goals and the special strengths you believe you may bring to a primary care specialty profession.

Have you applied or made a commitment to receive any funding that requires you to practice primary care in the state of Indiana or elsewhere? Yes No

If YES addresses the funding source within your statement.

Attach your Personal Statement.

Section D: Letters of Recommendation

The Selection Committee requires that the applicant provide at least two letters of recommendation. One recommendation may be from a physician who knows of your interests and career goals. The second recommendation may be from someone who knows you well enough that also knows of your interest and career goals. Both recommendations should also address your relevant employment, commitment to primary care, community service, character skills, and involvement in serving others.

Letters of Recommendation should be mailed to: 635 Barnhill Drive, MS 112, Indianapolis, IN 46202

Recommenders

Section E: Certification Statement

I certify that the information given in this application is accurate and complete to the best of my knowledge and belief.

First * Last *

Questions? Please reach out to jespada@iu.edu.