NMA WEB Application

2004-05National Medical Association Special Award Programs

Candidate Instruction Sheet

The National Medical Association is sponsoring three special award programs that recognize and reward African-American/black medical students for special achievements, academic excellence, leadership and potential for significant contributions to medicine.

The Patti LaBelle Scholarship and The NMA Emerging Scholar Awards are the highest honors presented to students by the National Medical Association. These awards recognize academic achievement, leadership and potential for distinguished contributions to medicine. Presented to current first, second, and third-year medical students, these awards also have a need component.

The Patti LaBelle Scholarship will be presented this year to the highest ranked candidate; the cash prize is $5,000. Each NMA Emerging Scholar Awards will include a cash prize of $2,250.

The JNMA Awards for Medical Journalism are given to students who demonstrate skill and interest in medical journalism. These awards also recognize academic achievement and leadership. Candidates must be in the third or fourth years of medical school and must have published articles and photographs in, or been writers, editors or photographers on the staffs of:

• Medical school newspapers;
• Medical student journals, such as the Journal of the Student National MedicalAssociation or the New Physician magazine;
• Recognized professional journals such as the Journal of the National Medical Association, the Journal of the American Medical Association, or the New England Journal of Medicine; or
• Other respected scientific journals.

Students who have written, produced or directed health-related films, commercials or videos are also encouraged to submit their applications and samples of their work in consideration for an Award in Medical Journalism.

The Awards in Medical Journalism include a cash prize of $2,500.

Eligibility and Selection Criteria

Eligibility for these awards is limited to African-American medical students. Your school may submit two nominations for NMA Emerging Scholar Awards and two for the Awards in Medical Journalism—a total of four nominations.

The general application materials submitted for each nominee must include:

• A letter of recommendation that fully discusses the candidate’s academic performance, extracurricular activities and other qualifications for the scholarship.
• A scholarship program application form in which the student provides basic biographical and educational information.
• An essay of at least 500 words written by the student. The essay should discuss his or her motivation for a career in medicine and career plans over the next ten years.
• An official academic transcript.
• For Emerging Scholar nominees only: A financial aid transcript submitted by the medical school financial aid office, that itemizesthe sources of scholarship and loan support as well as an estimated budget and award package for the 2004-05 year. Students must also provide income tax returns for themselves, their parents and spouses. The required form is included with the application.

• Applicants for the JNMA Awards in Medical Journalism must also submit samples of their work (articles, photographs, audio tapes, video tapes, etc.) for review by the selection committee. Printed articles and photographs may be submitted in the form of clippings, reprints or photocopies showing the names and dates of the publications in which they appeared. Broadcast (radio and television), film and video entries should be submitted as scripted material accompanied by audiocassettes or 3/4" videocassettes. Entries must have been published or produced within the last three years.

NMA Merit Scholars will be selected on the basis of:

• Documented financial need
• Leadership and community involvement
• Academic achievement
• Potential for outstanding contributions to medicine

The criteria for selecting the JNMAMedical Journalism Scholars include:

• Demonstrated journalistic skill
• Leadership and community involvement
• Academic achievement
• Potential for outstanding contributions to medicine

Deadline Date and Announcement of Winners

The deadline for submission of application materials is May 7,2004. Award winners will be announced to the medical schools by June 30, 2004 and at the annual convention of the National Medical Association in August. Award checks will be distributed in September 2004.

THE ORIGINAL PLUS ONE COPY OF ALL APPLICATION MATERIALS SHOULD BE FORWARDED IN ONE PACKAGE TO:

The National Medical Association Special Awards Programs

National Medical Fellowships, Inc.

5 Hanover Square, 15th Floor

New York, NY 10004

(212) 483-8880

The National Medical Association

Special Award Programs

2004 Application Form

[] Please check here if you are applying for an Award in Medical Journalism

Please Print All Responses

Name: SSN:

LastFirstMI

MedicalSchool:

Year in School: Expected Date of Graduation:

Date of Birth: Place of Birth:

Gender:Male Female U.S. Citizen:Yes No 

If naturalized citizen, please provide certificate number:and include proof of citizenship

Marital Status: WidowedSingleMarriedDivorced

Spouse’s Name: ______

How did you learn about this program?

Current Address:

NumberStreetApt. #

CityStateZipTelephone

Permanent Address:

NumberStreetApt. #

CityStateZipTelephone

E-Mail Address:

Parental Information

Father: Mother:

Occupation: Occupation:

Address: Address:

City/State/Zip: City/State/Zip:

Telephone: ( ) Telephone: ( )

EDUCATION

List all honors or awards received in undergraduate, graduate and medical school. (Use additional sheets if necessary)

List all research fellowships received in undergraduate, graduate and medical school. (Use additional sheets if necessary)

List in chronological order, major professional, social, civic and student organizations, in which you have participated over the past four years, include offices held. (Use additional sheets if necessary)

For NMA The Awards in Medical Journalism

Type of submission(s) (Check all that apply)

____School newspaper_____Professional journal_____Video

____School magazine_____ Radio

____ Student journal_____Television

Titles of entries submitted:

For newspaper and magazine entries:

Published in Date

For radio or television entries:

Original date and time of broadcast

Station Length of original program

Length of material entered

For video entries:

Audience and purpose of video

Length of material entered

How was material distributed and by whom

Personal Statement: All applicants must provide a statement of least 500 words discussing your personal and professional goals over the next ten years. Emphasize significant persons and/or events that have influenced your decision. Your name, medical school and social security number must appear on each page.

I authorize my medical school to release information concerning my academic status and financial aid package to National Medical Fellowships, Inc. in support of my application for a National Medical Association award. I understand this application will be reviewed by members of the NMA Council on Talent Recruitment, Retention and Financial Aid and give my permission for this application and supporting documentation to be copied and distributed for this purpose. My signature affixed to this page also authorizes NMF to request follow-up information about me from my medical school, state licensing boards and all professional and academic associations with which I have or will have an affiliation or from which NMF can retrieve biographical and career information.

List the names of your hometown and local/school newspapers.

______

Please forward original plus one copy of all required application materials to:

National Medical Association Special Awards Programs

National Medical Fellowships, Inc.

5 Hanover Square, 15th Floor

New York, NY10004

(212) 483-8880

Deadline for receipt of application materials: May 7, 2004

Faxed applications will not be accepted.

The 2004 National Medical Association Special Award Programs

Application Checklist

A Recommendation from the medical school dean or assignee

Completed Application

Personal Statement

Official Academic Transcript

A Financial Aid Transcript–For Emerging Scholar Awards nominees only

Samples of Printed Articles, Photographs, Audio Tapes, Video Tapes, etc.–For NMA Awards in Medical Journalism nominees only

The Original and One Copy of All Application Materials should be forwarded

By May 7, 2004to:

The National Medical Association Special Awards Programs

National Medical Fellowships, Inc.

5 Hanover Square, 15th Floor

New York, NY10004

(212) 483-8880

Facsimiles will not be accepted.

FINANCIAL AID TRANSCRIPT AND EVALUATION FORM – NMA PROGRAM

INSTRUCTIONS: An NMF scholarship applicant attending medical school must submit this transcript to document all financial aid received at the medical school. The applicant should complete Section A and have the financial aid office at the medical school complete Section B and return this form to NMF by May 7, 2004.

SECTION A: (To be completed by applicant)

Name previously used at medical school (if different from above)______

I authorize the financial aid office at ______, which I have attended

Name of School

since ______to provide the information requested by NMF.

Month/Year

SECTION B: (To be completed by the financial aid office at the medical school)

A COMPLETED TRANSCRIPT IS NECESSARY IN ORDER FOR YOUR STUDENT TO BE CONSIDERED FOR AN AWARD.

TOTAL GRANTS/SCHOLARSHIPS

OVER

Academic year for whichMedicalSchool

assistance is requested:______Class Year:______

Please itemize the actual cost to be incurred by the student at your institution this year:

Is this student subject to higher non-resident tuition cost?YES NO

This transcript must be received by NMF’s office no later than May 7, 2004in order to complete your student’s scholarship application.