2019 SHSMD Connections Scholarship Program | Application Form

Recommendation Letter, Contact Information and Professional Profile

Submission Deadline: May 30, 2019

It is recommended that this downloadable form be used to conduct any pre-work before completing the below application form. A thank-you page stating "APPLICATION RECEIVED" will serve as confirmation that your application has been received.

Question Title

* 1. Letter of Recommendation from Employer | Manager, Department Head or CEO
(If unemployed, from Professional Reference)

Must include signature and statements attesting to applicant's (1) relevant work experience and responsibilities, (2) need for professional development and (3) financial need (if unemployed, financial need statement may be omitted)

PDF, DOCX, DOC file types only.

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Question Title

* 2. Applicant Contact Information

Name

Title

Organization

City

State

Email Address

Phone Number

Question Title

* 3. Organization Type:

Hospital

Health system

Academic medical center

Rural hospital

Children’s hospital

Ambulatory care center

Long-term-care center

Skilled nursing facility

Subacute care or rehab facility

Physician group

Other healthcare provider

Academia

Association

Consulting firm

Vendor

Unemployed

Other (please specify)

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* 4. Prior Employers
(Include dates of employment for each, e.g., YYYY-YYYY)

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* 5. Total Years in Healthcare

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* 6. What has been your most meaningful professional achievement?
(Up to 300 words)

Question Title

* 7. What are your professional goals for the next three to five years?
(Up to 300 words)

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33% of survey complete.

Question Title

* 1. Letter of Recommendation from Employer | Manager, Department Head or CEO(If unemployed, from Professional Reference)

Question Title

* 2. Applicant Contact Information

Question Title

* 3. Organization Type:

Question Title

* 4. Prior Employers(Include dates of employment for each, e.g., YYYY-YYYY)

Question Title

* 5. Total Years in Healthcare

Question Title

* 6. What has been your most meaningful professional achievement? (Up to 300 words)

Question Title

* 7. What are your professional goals for the next three to five years? (Up to 300 words)

* 1. Letter of Recommendation from Employer | Manager, Department Head or CEO
(If unemployed, from Professional Reference)

* 4. Prior Employers
(Include dates of employment for each, e.g., YYYY-YYYY)

* 6. What has been your most meaningful professional achievement?
(Up to 300 words)

* 7. What are your professional goals for the next three to five years?
(Up to 300 words)