Financial Aid Application

2018-2019
Geisel School of Medicine

The policy of the Geisel School of Medicine is to support equality of opportunity for persons, regardless of race or ethnic background. No student will be denied financial aid, or be otherwise discriminated against, because of age, disability, race, color, sexual orientation, religion, sex, or national or ethnic origin. Federal regulations governing Title IV programs require United States Citizenship or Permanent Resident status as a stipulation for eligibility for federal aid. This form is required for all students applying for any type of financial aid from the Geisel School of Medicine.

Entries marked with * are required.

I. Applicant Information

Last Name*:

First Name*:

Middle Name:

Preferred Name*:

Student ID:

If you are a returning student,
please enter your student ID

Permanent Address*:

City*:

State*:

Zipcode*:

Mailing Address*:

City*:

State*:

Zipcode*:

Phone Number*:

Email Address*:

Date of Birth*:

Calendar

Place of Birth*:

Citizenship*:

Gender*:



Eligible Non Citizen (for non US Citizens):



Number of dependents*:

include self, spouse & children

2018-2019 Year in school at Geisel*:

If you have attended Dartmouth College, please complete the following:

Years attended, from:

i.e. from 9/10 ...

To:

... to 6/12

Program you were enrolled in:

Did you receive Federal Stafford Loans while enrolled:



II. Special Information

Please describe any special circumstances which should be considered in evaluating your request for financial aid*:

Have you identified yourself to AMCAS as an Ohio resident and wish to be considered for the Ohio Scholars Program*:



III. Default/Refund Verification

By signing this application, I certify that I am not in default on any Federal Stafford, Federal Perkins, or GradPLUS loan that I received while attending any institution, nor do I owe a refund on any PELL, SEOG, or SSIG grant received for attendance at any institution. I also certify that all the information reported to qualify for federal aid is complete and accurate.

I have read and understood the Default/Refund Verification Statememt*:


Signature*:

Date:

11/18/2017

IV. Statement of Need/Understanding

I, the undersigned, hereby state that financial aid is essential to enable me to continue my education at the Geisel School of Medicine. As a financial aid recipient, I am expected to notify the Financial Aid Office of any circumstances which significantly improve or diminish my financial resources or those of my family; contribute each year from my savings and/or summer earnings toward my medical school expenses; maintain satisfactory academic progress; and report to the Financial Aid Office any aid received from outside sources. I understand that the information provided on this and other documents may be shared with the government and private agencies from which I am requesting aid, and with scholarship donors if aid is offered and accepted. The information submitted is true and accurate.

I have read and understood the Statement of Need/Understanding*:


Signature*:

Date*:

11/18/2017