Form 1 SDS Program Specific Data Application_11-18-19

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SOS Program Specific Data Forms
F1el& marbd mil, a a,tui,k (') aH requlr,d

Scholarships for Disadvantaged Students Program Specific Form

Prosuam Sl'.N!d1k Information

*Note: The institution MUST be a public or non profit institution, in order to be eligible for sos·funds for any discipline. The following list of disciplines are the ONLY exceptions to the ru'le:
• Nlmsing (Associate, Baccalaureate, Diploma or Graduate)
• Physician Assistant [Associate, Baccalaureate or Graduate)

(For example: If the institution is applying for any of the discip'lines mentimed above, it need NOT be public or non profit).
•Tobe e-ligible a school/program mu1st be accredited by the relevant acc rediting body approved for sud1 p•urpose by the Secretary of Education.

..

Scbolarsbius for Dis.advanta11ed Students
Current Fiscal Year

Sel�ct One

(Sded 'the fi5c..1.l year date th.at j,_ prcrvided in. the current SOS. Ftmt3iris Opportullify -�eIClBl.l: cm:er �e)

2016

202�
• ADD DISCIPLINE

Se'lect your Discipline

V

Select One
Allopathic Medicine • Doctoral

Osteopathic Medicine• Doctoral

•A. l"UBLICOR NON l"ROFff INSTITUTION

Is your school/program .an .accredited public or an aocredited non profit institution?

r

Yes

r

No

Contact Information
•o. l'OINT OF CONTACT
Person Information

Title

TextbOll

*First Name

Te:xtbox

"Last Name

Textbox

*Email Address

TextbOll

*Phone Number

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