Fauquier Auxiliary Healthcare Scholarship Application Survey

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1. Demographic Information

Demographic Information Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

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2. Date of Birth

	Month	Day	year
Date of Birth	Date of Birth Date of Birth Month	Day	year

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3. List the college or university that you are presently enrolled in or have been accepted to.

List the college or university that you are presently enrolled in or have been accepted to.

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4. What are your tentative plans for your healthcare career?

What are your tentative plans for your healthcare career?

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5. Please list you school activities.

Please list you school activities.

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6. Please list your community activites.

Please list your community activites.

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7. Please list your honors and awards.

Please list your honors and awards.

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8. Please list your employment history.

Please list your employment history.

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9. Please explain why you have chosen to pursue a healthcare career.

Please explain why you have chosen to pursue a healthcare career.

10. You are required to submit the following documents to Hospaux@fauquierhealth.org.
Please confirm that you are in the process of completing this documentation.
All documentation must be received by March 28, 2013 in order to be considered for this scholarship.
Incomplete applications will be discarded after the deadline date.
Questions? Call 540.316.2910.

You are required to submit the following documents to Hospaux@fauquierhealth.org. Please confirm that you are in the process of completing this documentation. All documentation must be received by March 28, 2013 in order to be considered for this scholarship. Incomplete applications will be discarded after the deadline date. Questions? Call 540.316.2910. All Applicants - Letter of recommendation from your academic adviser

All Applicants - A transcript of your grades

High School Seniors - A copy of your college Board scores

High School Seniors - A copy of your college acceptance letter

High School Seniors - A parent/guardian release of transcript form (download from the Fauquier Health webpage, scholarship section.)

College or University Students - A proof of enrollment.