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Mintz Scholarship Application
Please complete the following application for scholarship consideration.
All fields required, if applicable. Additional information is required; view complete rules and requirements for details.
BIOGRAPHICAL INFORMATION
First Name:
Last Name:
Gender:
choose one
Male
Female
Date of Birth:
?
Email:
Cell:
Home Address:
City:
State:
Zip:
School Address (If Different):
City:
State:
Zip:
Preferred Mailing Address (choose one):
Home Preferred
Work Preferred
Marital Status:
choose one
Single
Married
Divorced
Dependents:
Number of Family members (including self):
Number of Family members in college (including self):
Have you ever been a New Jersey resident?
choose one
Yes
No
If so, when were you a resident?
City/State where you intend to practice:
Optometric School:
Anticipated date of graduation:
?
Current Cumulative GPA in optometry school (Undergrad GPA if 1st year):
OTHER COLLEGIATE INFORMATION
Name/Location of school:
Years in Attendance:
Degree Awarded:
Name/Location of school:
Years in Attendance:
Degree Awarded:
Optometric Organizations & Offices:
Community Organizations & Interests:
Please list any on or off campus employment you have held during optometry school:
Special Optometric Interests:
Leadership Involvement within Organization:
FINANCIAL INFORMATION
Student's Expenses
Last Academic Year
Anticipated this Academic Year
Tuition and Fees
Books/Supplies/Equipment
Living Expenses (including rent/mortgage)
Transportation
Health-related Expenses
Miscellaneous
TOTAL
Student's Income
Last Academic Year
Anticipated this Academic Year
Aid from student's parents
Student's wages after taxes
Spouse's wages after taxes
Other income
Grants/Scholarships
Loans
TOTAL
STUDENT'S ASSETS AND INDEBTEDNESS
All Bank Account Balances:
Other Investments/Assets:
Total Student Loan Indebtedness:
(include undergraduate and current year loans)
Other Indebtedness (please explain):
$
During the last two years, did the parents claim the student as a dependent?
choose one
Yes
No
Will the student be a dependent this year?
choose one
Yes
No
Mother's Name:
Address:
City:
State
Zip
Father's Name:
Address (if different from Mother):
City:
State
Zip
- denotes required fields
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