Page 24 - SCIE Ambassador Program Strategic Brief

APPENDIX B Application Form

SCIE Ambassador Program

Program Participant Application
Last Name First Name Middle Initial

Current Address

City State ZIP Code

E‐mail Address Home Phone Number Cell Phone Number

Gender Date of Birth Citizenship
□ Male □ U.S. Citizen
□ Female □ Permanent Resident
□ Other: _________________________ □ International Student
Ethnicity Educational Background MCV

American Indian/Alaskan □ School of Allied Health Professions
Asian Undergraduate Institution: □ School of Dentistry
Black/African American ________________________ □ School of Medicine
Hawaiian/Pacific Islander □ School of Nursing
Degree Conferred/Year:
Hispanic/Latino □ School of Pharmacy
International ______________________ Year in Program (i.e., first year):
Two or More Races
_____________________________________
Unknown
White

Marital Status Dependents: Financial Aid Status
□ Single □ No Did you receive funding from your department?
□ Separated □ Yes: (ages) _______________________________ □ Yes □ No
□ Married If yes, please specify:
_____________________________________
□ Widowed
__
_____________________________________
__
All applicants must complete and submit the following documents for the application to be reviewed:
 The SCIE Ambassador program participant application
 Resume/Curriculum Vitae

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