Rural Georgia Senior Application

Name*

First Last

Preferred Name*

Date of Birth*

Primary Email Address*

Alternate Email Address

Cellphone Number*

MUSM Location*

Current Residence*

Street Address Address Line 2 City State ZIP Code

Permanent Home Address*

Street Address Address Line 2 City State ZIP Code

County of Permanent Residence*

Name of High School Attended*

Town, County and State of High School Attended*

What city do you consider to be your hometown?*

Speciality of Interest*

Check all that apply

Family Medicine
General Internal Medicine
General Pedicatrics
Obstetrics and Gynecology
Psychiatry
General Surgery

List all cities/counties, states where you have resided since birth. Include dates (MM/YYYY) of residency.*

Example: Tifton, GA (04/1992-07/2010); Athens, GA (08/2010-05/2014); Tifton, GA (05/2014-date)

What specialties have you applied to and why did you choose these specialities?*

What are you looking for when applying to a residency program?*

Have you applied to any Georgia residency programs? If so, which ones?*

What are your career plans?*

Describe your rural life experiences and desire to reside in a rural Georgia county.*

What do you believe are the challenges and benefits of practicing primary care in a rural medically underserved Georgia County?*

Service Commitment

By submitting this application, I understand that if I am awarded this scholarship, I will be required to work AND reside in a Georgia county with a population of 50,000 or less, as approved by the School of Medicine, for a minimum of five years.

Yes, I understand and agree to the service commitment requirement.

Rural Georgia Senior Scholarship