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	Answer each question as completely as possible.
	Use upper and lower case letters, do not use all capital letters.
	Do not use a semicolon (;) in any of your responses.
	Check your answers.  After you hit the submit button, answers can not be changed.

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First name:
Last name:
University PID number:		(9-digit number no dashes)

Pharmacy School Class:

Class of 2002 Class of 2001 Class of 2000

 

 

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Educational Background

If you have been awarded a prior degree, please select the appropriate box(es) below and indicate your major and the institution where the degree was conferred.

BS/BA	No Yes	Major:	Institution:
Masters/JD	No Yes	Major:	Institution:
Ph.D.	No Yes	Cognate:	Institution:

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Co-Curricular Activities

Please indicate whether you participated in the following pharmacy organizations at any time during your enrollment in the UNC School of Pharmacy.

Senate		Officer	No official participation
Class Officer		Officer	No official participation
SNPhA	Member	Officer	No official participation
CAPS	Member	Officer	No official participation
TABS	Member	Officer	No official participation
SHAC	Participant	Liaison	No official participation
CPSF	Member	Officer	No official participation

Please indicate whether you participated in the following professional fraternities at any time during your enrollment in the UNC School of Pharmacy.

Kappa Epsilon	Member	Officer	No official participation
Kappa Psi	Member	Officer	No official participation
Phi Delta Chi	Member	Officer	No official participation

Please indicate whether you participated in the following pharmacy honoraries at any time during your enrollment in the UNC School of Pharmacy.

Rho Chi	Member	Officer	No official participation
Phi Lambda Sigma	Member	Officer	No official participation

Please indicate whether you participated in the following campus organizations at any time during your enrollment in college.  

• Do not include pharmacy-related organizations. 
• Check all that apply.
• List the name of the organization or group in the column on the right.

Check all that apply.
Cultural and International Organizations
Fraternity/Sorority (Social)
Honorary & Service Organizations
Music and Performance Groups
Religious Organizations
Residence Hall Advisor
Special Interest Groups
Sports and Recreation Teams
Student Government
Other organization, not listed

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Past Scholarships

Please list the name, sponsor, and dates of any merit scholarships you have received while in college.

Scholarship	Sponsor	Year(s) Awarded
1.
2.
3.

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Written Questions

Please answer the following questions briefly and concisely.

A. What has been your most meaningful contribution to the School of Pharmacy or the pharmacy profession this year?

B. If you have been employed during the current school year, please indicate the name of the business, the nature of your work, and the average number of hours worked per week.

C. If you were employed last summer, please indicate the name of the business, the nature of your position, and the average number of hours worked per week.

D. In what area of professional practice are you interested at this time?   Why?

E. Please describe an activity you completed in the last year which you believed contributed to your personal development.

F. What is the most important health problem facing the United States today?

G. Please indicate in the space provided why you believe you should receive scholarship support from the School of Pharmacy.

Information for Awards with Specific Criteria

The following questions are used for scholarships with specific award criteria.

The Jeffrey Jordan Scholarship gives preference to students with significant financial need as determined by the University.   How much was your total financial aid award for the current academic year?		not applicable $1-500 $501-$1000 $1001-1500 $1500-2000 $2001-2500 $2501-3000 $3001-3500 $3501-4000 $4001-4500 $4501-5000 $5001-5500 $5501-6000 $6001-6500 $6501-7000 $7001-7500 $7501-8000 $8001-8500 $8501-9000 $9001-9500 $9501-10,000 Greater $10,000
Have you applied (or will you apply) for financial assistance from the University of North Carolina at Chapel Hill for the next academic year?		No Yes
The Jesse Stewart Scholarship gives preference to the child of a pharmacist.  Select yes if you qualify and would like to be considered for the award.		No Yes
Several awards give preference to applicants with the intention of working in a specific practice site.  Which of the items best describes the practice setting in which you are most interested in working?		undecided clinic ambulatory care independent pharmacy chain pharmacy hospital pharmaceutical industry home health care nuclear long-term care mail order government position academic non-pharmacy position
After graduating from the School of Pharmacy, which of the items best describes your career plan?		undecided employment as a pharmacist fellowship or residency graduate school law school medical school administrative non-pharmacy position
The Rozelle McCranie Scholarship gives preference to a single parent. Select yes if you qualify and would like to be considered for the award.		No Yes
The Raymond Yingling Scholarship gives preference to applicants from Robeson or other underserved counties in NC.  If you are a legal resident of NC, what is your permanent county of residence?

 

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Demographic Information

The following questions are for administrative use only.  This information is voluntary and is not used for awarding scholarships.

Permanent Street Address:
City:
State:
Zip:

 

Phone Number:
Email Address:

Year of birth:		19
Current Age:
Gender:		No response male female
Race/Ethnicity		No response Black/African-American White, non-Hispanic Hispanic Asian Native American Non-Resident Alien

 

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Your Comments to the Scholarships Committee

Use the box below to provide the Scholarship Committee with comments on improving the awards application or selection process.   Positive comments are helpful too.

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WARNING PLEASE READ: CHECK YOUR ANSWERS BEFORE USING THE 'SUBMIT' BUTTON BELOW.  ONCE YOU HAVE SUBMITTED YOUR FORM, THERE WILL NOT BE A WAY OF CORRECTING THE INFORMATION. AFTER YOU HIT "SUBMIT", WAIT UNTIL THE NEXT PAGE APPEARS.  THIS PAGE CONFIRMS YOUR SUBMISSION.  PRINT THE NEXT PAGE AND TURN IT IN TO THE OFFICE OF STUDENT SERVICES, ROOM 117, BEARD HALL, BY 5:00 PM, MAR 22, 1999.

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