Step 1 of 7 14% General Information * Indicates field is required.Name* First Middle Last Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone:*Work Phone::Email:* Date of Birth:* MM DD YYYY Age:*Sex:*MaleFemaleOtherSocial Security Number:Citizenship:*US CitizenPermanent Resident School & Income Information * Indicates field is required.School, program and degree/ certification:*Have you been formally accepted?*YesNoProgram Start Date;*Length of Program:*For academic year / program start date:*If currently enrolled in the program, how many semesters / months remaining to completion?*Are you attending full time (12 units or more per semester)?*YesNoEstimated annual tuition, fees and books:*Scholarship Requested:*Have you been awarded any other scholarship or grant for the academic year for which you are applying?*YesNoIf yes, what is the amount of the reward?What will the award fund?Your annual income?*Number of family members living in your household?*Parent's annual income, if you are dependent:Career ObjectiveWhat is your career objective?*Medical AssistantMedical TechnicianDental AssistantDental TechnicianLicensed Vocational Nurse (LVN)Registered Nurse (RN)Registered Nurse Practitioner (RNP)Physician Assistant (PA)Clinical PharmacistDentistPhysicianOther Post Graduate Healthcare ProviderOther Post Graduate Healthcare Provider Loan Repayment * Indicates field is required.Employer:Position:Employer telephone:Employer fax:Employer address:Work status:Full TimePart TimeWork hours:Hire Date:Lender name:Current loan balance:Monthly payment:Is your loan past due?YesNoEducation Levels of education achieved:High School DiplomaAssociates DegreeBachelors DegreePhDMDDDSHigh School details:Associate's Degree details:Bachelors Degree details:PhD details:MD details:DDS details:Other details:License # ( If Applicable ):If diploma or degree was conferred to you under a different name, please state the name to which it was conferred:Please list languages where you are proficient, including level of written and verbal fluency:* Other * Indicates field is required.Have you ever been convicted of felon or misdemeanor?*YesNoIf yes, please explain:Extra Curricular Activities, Achievements, Awards:Employment / Volunteer History: Documents * Indicates field is required. Allowed files types: (Excel,PDF,Text,Word)Upload personal statement:*Upload letter of recommendation & form #1:*Upload letter of recommendation & form #2:*Upload most recent federal income return (1040 or 1040EZ):*Upload FAFSA:*Upload curriculum vitae or resume:* Certification I certify that I have provided complete and accurate responses to the items on this application. I further certify all documents submitted to support this application are authentic and unaltered records that pertain to me. I certify that I will use scholarship funds for educationally related expenses. If approved for the loan repayment program, I agree to notify QueensCare and / or its designee within 10 days if my current employment is terminated or my status changes from full time. My signature certifies the accuracy and completeness of the information provided. I understand that any misrepresentation may be cause for denial or cancellation of awards offered or granted. I also understand that all scholarships or loans given to me must be claimed within one year of being awarded. * Indicates field is required. Signature:*Date:*Along with the above-mentioned documents, your institution must send Official Transcripts electronically to info@queenscare.org or by mail to: QueensCare Scholarships Fund, 950 S Grand Ave. Los Angeles, CA 90015. All transcripts must be postmarked by May 1st of the year you are applying. Submit Your Application Review your information. If anything is incorrect go back to update and save. {all_fields}
