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					         GLEN JOHNSON, MD MINORITY MEDICAL STUDENT
                        SCHOLARSHIP

The Texas Academy of Family Physicians Foundation established this scholarship fund
to honor TAFP Past President Dr. Glen Johnson. This scholarship will be awarded to a
third or fourth year medical student at a Texas medical school who is an underrepresented
racial/ethnic minority and has demonstrated an interest in family medicine. Preference
will be given to African American medical students. The scholarship is administered
through the Texas Academy of Family Physicians Foundation, the philanthropic arm of
the TAFP.

Eligibility Criteria
        1. Third or fourth year medical student in good standing at a Texas medical
           school.
        2. Student is an underrepresented racial/ethnic minority.
        3. Student has a strong interest in family medicine or has already chosen family
           medicine.
        4. Student is able to attend the Texas Academy of Family Physicians Annual
           Session held in July in order to be presented the scholarship check.

Selection
        1. Student meets the above eligibility criteria.
        2. Completed application.
        3. Letter of recommendation from a faculty member or preceptor.
        4. Copy of medical school transcript.
        5. Copy of curriculum vitae.


Timeline
       Deadline for submission of applications:                              May 9, 2012
       Selection/notification of scholarship recipient                       June 1, 2012
       Scholarship awarded to student:                          TAFP Annual Session in
                                                             Austin, Texas, July 14, 2012
    Glen Johnson, MD Minority Medical Student Scholarship
                                   Application Form


(Please print or type)


Name            ____________________________________________

Race/Ethnic category _______________________________________

Address         ____________________________________________

City, Zip    ____________________________________________

Telephone     ____________________________________________

Pager #         ____________________________________________

Email           ____________________________________________

Please briefly describe your plans for a career in family medicine:
Page 2
Provide a brief personal statement: (Include information such as where you are from,
your family, educational background, interests, hobbies, etc.)




Have you been involved in a Family Practice Student Association/Interest Group?
___________Yes __________No
If yes, describe your participation.




References. Please provide the names and phone numbers of two physicians whom we
could contact to ask about you. If possible, provide the names of family physicians.

1. ______________________________________________________________________
   Name                                                      Telephone

2. ______________________________________________________________________
   Name                                                      Telephone

Please attach your curriculum vitae.

Please note: A combination of factors (commitment to a career in family medicine,
quality of personal statement, academic performance, faculty recommendations etc.) will
be considered in selecting the recipient of this scholarship. We appreciate your interest in
applying.

               Texas Academy of Family Physicians Foundation
               Attention: Kathy McCarthy
               12012 Technology Blvd., Suite 200
               Austin, Texas 78727
               512-329-8666, ext 14
               e-mail: kmccarthy@tafp.org

				
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