EmailMe Form - SOMA Scholarship Application

Name

First MI Last

Credentials/Rank

Organization (if any)

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Phone

### - ### - ####

Email

SOMA Membership ID and Join Date (if known)

Medical Education Program Information

Please note that at the end of this form, you will be required to upload proof of acceptance/enrollment at the institution indicated.

University/Institution

I am:

Accepted in an accredited health/medical program.

Currently enrolled in an accredited health/medical program.

If accepted, what is your anticipated start date?

If enrolled, what is your current class year and anticipated graduation date?

Estimated Out-of-Pocket Expenses

$ Dollars

Other Financial Assistance

Are you the receipient of other scholarship funds, benefits and /or financial assistance?

Yes

No

If yes, please describe and include award amount.

(limit 100 words)

Current Employment

Will you be employed while attending school?

Yes-Full Time

Yes-Part Time

No

Unknown/Undecided

If yes, please describe and include projected income.

(limit 100 words)

Military Service

Please note that at the end of this form, you will be required to upload any/all application "DD Form 214" to this application. Please be sure to redact your social security number and birthday before doing so.

Branch of Service

Air Force

Army

Marine Corps

Navy

Service Type

Active Duty

Reserve/National Guard

Were you ever deployed to a combat theater of operations?

Yes

No

Medical AFSC/MOS/Rating Held (include code and description)

SOF Qualification(s)/Assignment(s)

If other, please indicate:

Other Federal Service

Please note that at the end of this form, you will be able to attach any/all applicable "TDY Orders," "CED Orders," "Letters of Authorization," and/or other pertinent information.

Please be sure to redact your social security number and birthday before doing so.

Classification of Service

Government Civilian

Government Contractor

Did you function in a medical provider capacity?

Yes-Primary Role

Yes-Secondary Role

No

Were you ever deployed to a combat theater of operations in this role?

Yes

No

Other Relevant Service/Employment/Volunteer

Did you function in a medical provider capacity?

Yes-Primary Role

Yes-Secondary Role

No

If yes, please describe.

(limit 300 words)

Supporting Documentation

Before uploading, please be sure to redact personal information from the documentation that you do not want shared, including your social security number and your birthdate.

Do not submit classified or otherwise sensitive information.

Medical Program
Proof of acceptance/enrollment in a health/medical program at an accredited medical institution/university.

Military Service
DD Form 214

Other Federal Service
(TDY Orders, CED Orders, Letters of Authorization, etc.)

Essay
The essay presents you an opportunity to speak directly to the Scholarship Committee. Keep in mind that we are looking for candidates with a strong sense of purpose, service, and commitment, who intend to continue serving their community and their country. Limit your document to no more than three pages. Provide:

- a brief personal introduction,
- past lessons learned,
- plans for the future,
- why/how the scholarship money will help you accomplish your mission(s), and
- any additional information about yourself, including where you've been and where you'd like to go (metaphorically-speaking).