IPA Scholarship Application
Address *
(Street, City, State, Zip)
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Name *
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Pharmacy School you are a student at *
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Expected Year of PharmD Graduation *
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Cell Phone Number *
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Email address *
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IPA Member Since *
(Year)
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Current GPA in Pharmacy School *
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Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
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Organized by
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Location/Duration/Date
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Number of Participants
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Your role or activities
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Supervised by
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Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Activities Tell us in which areas you have volunteered (Health Fairs, Student Clubs, IPA events, advocacy, etc)
Event or Activity
Your answer
Organized by
Your answer
Location/Duration/Date
Your answer
Number of Participants
Your answer
Your role or activities
Your answer
Supervised by
Your answer
Additional skills or activities *
Summarize special skills and qualifications you have acquired from employment, previous volunteer work, or through other activities.
Your answer
Agreement and Signature : By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a finalist or awardee, any false statements, omissions, or other misrepresentations made by me on this application may result in disqualification. *
Name
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Thank you for completing this application form and for your interest in this award. Please click submit to record your responses. In case of any error messages or difficulty with this form, please email. *
You will be notified as per deadlines above. From THE IPA SCHOLARSHIP COMMITTEE. Please address all questions to: Anandi V. Law alaw@westernu.edu PLEASE DO NOT CONTACT THE COMMITTEE TO ASK ABOUT RESULTS. AWARDEE WILL BE ANNOUNCED AT THE ANNUAL EVENT ON SEPTEMBER 6, 2014.
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