[Click Here to Download the Medical Scholarship Application]

The Glens Falls Foundation Pesquera Scholarship Fund

Grant Application 2011

The Pesquera Scholarship Fund awards grants to second, third and fourth year medical school students. The deadline for applying and receipt of supporting documentation is June 24th. Submit the application and all supporting documentation to Chairperson, Pesquera Medical Scholarship Committee:

Email: administrator@glensfallsfoundation.org

Or by mail to:

Glens Falls Foundation
237 Glen Street
Glens Falls, N.Y. 12801
The Student Must Apply Each Year and the Application is to include:
  1. Your official medical school transcript sent electronically or in a sealed envelope directly from your medical school;
  2. A brief personal statement describing your academic and occupational goals, interests, and activities;
  3. Names, phone numbers, and email addresses of two personal references (other than family) whom we may contact in regard to character, motivation and potential;
  4. This application, completed and signed.

Personal Information

Date:

Full Name:

Permanent Address:

City:

State:

ZIP code:

Email Address:

Telephone:

Cell Phone:

Marital Status:


Father's Name:

Father's Occupation:

Father's Employer:

Mother's Name:

Mother's Occupation:

Mother's Employer:

Parents' Phone Number:

Spouse's Name:

Spouse's Occupation:

Spouse's Employer:


Pesquera Scholarship Fund Application

 

List the secondary schools and colleges you have attended, dates of attendance, diplomas received (one school per line):






Name of Medical School you are attending and dates of attendance:

If you are working part-time, state your job and the hours per week:

List any employment you may have had for the last two years, including employer and dates:


Expenses and Resources

 

Medical School Expenses:
Tuition & Fees:
Books & Supplies:
Room & Board:
Personal Expenses:
Transportation:
Total:

Applicant's Financial Resources
Savings:
Earnings:
Parents:
Spouse:
Loans:
Scholarships:
Total:
Financial Assistance Needed:

List other scholarships received or for which you have applied, and state dollar amount, if known:









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237 GLEN STREET, GLENS FALLS, NY 12801 | 518-761-7350

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