Mahin and Saifulla Salemy High School Scientific Scholarship Application
Deadline: May 31, 2019

This scholarship is offered by Shahram Salemy, MD FACS.

Applicants must be high school seniors in the United States who have been accepted to and will be attending college (either 4-year or community) in the United States and have an interest in the sciences.

Two students will be honored with a scholarship award of one thousand dollars ($1,000.00) each, which will be issued to their accepting colleges.

The application process includes:
● Written application
● Personal statement
● 3 references (teachers or employers)
● In-person or other interview

Finalists will be chosen by the team at Dr. Shahram Salemy at its sole discretion, and will be notified by phone or email.


Email address *
First Name *
Last Name *
Phone *
Include area code
Street Address 1 *
Street Address 2
City *
State *
Zip Code *
High School Name *
Accepting College Name *
Personal Statement *
Please tell us about yourself. Please share what your educational and professional goals are, and how a scholarship might support them.
Personal References
Please provide the names and contact information for 3 personal references.
1. Name *
1. Phone Number (include area code) *
2. Name *
2. Phone Number (include area code) *
3. Name *
3. Phone Number (include area code) *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service