Medical Student Travel Scholarship Award - Georgia Vascular Society

Medical School*

Other Medical School*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Institution Email

Personal Email

Medical School Year*

Class Rank

Enter your class rank, if known.

Accomplishments and Leadership

What honors and awards have you received since entering college?

Begin with the most recent and include the date of receipt

List your leadership activities (i.e. offices held, etc. ) since entering college

List your research projects, volunteer activities and extracurricular activities

Tell us in 500 words of less why the scholarship is important to your career goals.*

Student Verification*

All the information I have provided in this application is accurate and is subject to verification by the Georgia Vascular Foundation.*