PARTNERS RADIOLOGY
MEDICAL IMAGING PROGRAM
LOAN FORGIVENESS APPLICATION
PERSONAL
INFORMATION
Name______________________________________________________________
Last First
MI
Address Line 1 ________________________________________________________
Address Line 2
________________________________________________________
City_________________________________________
State ____ Zip _________
Home Phone _________________________________
Work Phone _________________________________
Cell Phone _________________________________
Email
Address 1 _______________________________________________________
Email
Address 2 _______________________________________________________
Preferred
method of contact (Please circle one):
Email 1 Email 2 Home Phone Work
Phone Cell Phone
Social Security #
_____________________ Partners Employee: Y______ N _____
EDUCATION
High School__________________________________________________________
Address_____________________________City/State/Zip______________________
Diploma / Equivalency Degree ____Yes
____No
College_____________________________________________________________
Address______________________________City/State/Zip____________________
Diploma
/ Degree ____Yes ____No
College_____________________________________________________________
Address______________________________City/State/Zip____________________
Diploma
/ Degree ____Yes ____No
Other School(s)_______________________________________________________
Address______________________________City/State/Zip____________________
Diploma
/ Degree ____Yes ____No
WORK HISTORY
(List most recent information)
Partners HealthCare System Employees
must fill out the following information
Employer
____________________________________Dates ___________
Name From/To
Address____________________________City/State/Zip____________________
Position
___________________________________________________________
Department___________________________Supervisor_____________________
Employer____________________________________Dates____________
Name From/To
Address_____________________________City/State/Zip____________________
Employer____________________________________Dates____________
Name From/To
Address_____________________________City/State/Zip____________________
Employer____________________________________Dates____________
Name From/To
Address_____________________________City/State/Zip____________________
Have you collected Unemployment Compensation in the last year?
Y___N___ If “yes”, please provide dates unemployment
compensation was collected:
From/To
__________
RADIOLOGIC TECHNOLOGIST PROGRAM
INFORMATION
School Name:
________________________________________________________
School Address:
______________________________________________________
Have you applied and/or been
accepted into the program? ____Yes ____ No
When does the program begin?
______________________________________
When do you expect to complete
the program? ___________________________
FINANCIAL INFORMATION
What is the tuition cost for
each semester? ________________
(Please attach tuition cost
information from school’s catalogue)
Are you seeking scholarship
support for ____one year ____two years?
Have you applied for financial
aid through other sources? (Please explain)
_________________________________________________________
PERSONAL REFERENCES
List three (3)
personal references that we have your permission to contact on your behalf.
Name_____________________________Relationship________________________
Address___________________________ Phone_____________________________
Name_____________________________Relationship________________________
Address____________________________Phone____________________________
Name_____________________________Relationship________________________
Address____________________________Phone____________________________
How did you hear about this loan forgiveness program? (Please check one)
|
|
Guidance Counselor |
Television |
|
Coworker |
Human Resources |
Radio |
|
College Faculty |
Internal Partners email announcement |
Web Search |
|
Career Newsletter |
Newspaper |
Other ___________________ |
|
Friend |
Supervisor |
|
PERSONAL STATEMENT OF ACADEMIC AND CAREER GOALS
Please describe in essay form why
you are applying to the scholarship program. Please include a description of
your career and educational objectives, related experiences, your perceived
strengths and weaknesses, and which qualities you might bring to Partners
HealthCare System and to the larger world of allied health and medical
professions.
(Please submit the above essay
in a MS Word document)
I certify that my responses to the
above questions are true. I understand falsification of any of the above facts
or other information supplied by me is grounds for denying my scholarship
application from further review and consideration or discontinuation of a
scholarship (including immediate return of any funds provided).
Your signature
___________________________________Date_______________
SCHOLARSHIP
APPLICATION CHECK LIST
____3
Letters of Recommendation from Supervisors/Instructors/ Guidance Counselors
1) ___ 2) ___ 3) ___
____Letter of acceptance into Radiology
Imaging Program
____Application
____Personal
Statement
RECOMMENDATION FORM
Please describe how
the applicant has demonstrated his or her potential to complete a college-level
training program in the medical imaging sciences, and which personal qualities
they might bring to patients, staff, and colleagues in the Departments of
Radiology at Partners HealthCare System. Thank you.
Voluntary Affirmative Action Information Completion of the
Information Below is Voluntary
AN EQUAL OPPORTUNITY EMPLOYER
The following information is required
for various record keeping purposes in connection with Federal Government
reporting requirements and the Affirmative Action Program. Please be advised
that the information on this form is not part of your official application for
the Partners HealthCare System Medical Imaging Scholarship Program. It is
considered confidential and will not be used in any scholarship award
decisions.
Sex ____M ____F
RACIAL/ETHNIC CLASSIFICATION-PLEASE
CHECK ONE OF THE FOLLOWING:
[ ] Black (Not of Hispanic
origin): A Person having origins in any of the Black racial groups of
[ ] Asian or Pacific Islander: A
Person having origins in any of the original peoples of the Far East, Southeast
Asia, the Indian subcontinent of the Pacific Islands.
[ ] American Indian or Alaskan
Native: A Person having origins in any of the original peoples of North America
and who maintains cultural identification through tribal affiliation or
community recognition.
[ ] Hispanic: A Person of Mexican,
Puerto Rican, Cuban, Central or
[ ] White (Not of Hispanic origin): A
Person not classified into one of the four specific categories above; also
includes, by definition, persons having origins in any of the original people
of Europe, North Africa or the Middle East.
Special Notice to
Government contractors subject to the
Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of
1973 are required to take affirmative action to employ and advance in
employment qualified disabled veterans and veterans of the
Veteran Status [ ] Disabled Veteran [
] Handicap [ ]
This information will be considered
confidential, and refusal to provide this information will not adversely affect
your consideration for the Baccalaureate Completion Scholarship Program or, if
applicable, any other aspect of your employment or consideration for
employment.
This form to
be filed separately from the application.