The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

n7WFQtn8jLRhpqRhbxff8gQ6vAcWYacIRe3Nw9oVWJrLPrUqVnVy

Financial Aid Application

Returning?

A A A

If you need to notify our office of special circumstances regarding your financial situation prior to our review of this application, please email us at financialaid@siumed.edu.

Upon submission of this application, you will be taken to a document that contains Required Statements and other forms. In order for this application to be considered complete, please print and sign. Originals of these forms must be mailed to:

SIU School of Medicine
Financial Aid Office
P.O. Box 19624
Springfield, IL 62794-9624

First name:

* must provide value

Last name:

* must provide value

Birthday:

* must provide value

M-D-Y

Birthplace (city/state):

* must provide value

Email address:

* must provide value

Marital Status:

* must provide value

Number of Children:

* must provide value

Citizenship status:

* must provide value

U.S. citizen

Naturalized citizen

Permanent resident

reset

Date of naturalization:

* must provide value

M-D-Y

Alien registration #:

Permanent street:

* must provide value

Permanent city:

* must provide value

Permanent state:

* must provide value

Permanent zip:

* must provide value

Permanent area code / phone #

* must provide value

Same as Permanent Address:

Yes

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Preferred street:

Preferred city:

Preferred state:

Preferred zip:

Preferred area code / phone #

School name:

School city:

School state:

School attended from:

M-D-Y

School attended to:

M-D-Y

School 2 name:

School 2 city:

School 2 state:

School 2 attended from:

M-D-Y

School 2 attended to:

M-D-Y

School 3 name:

School 3 city:

School 3 state:

School 3 attended from:

M-D-Y

School 3 attended to:

M-D-Y

Lender name:

Loan type:

Amount loaned:

Interest rate

Date borrowed

M-D-Y

In deferment / repayment:

2. Lender name:

2. Loan type:

2. Amount loaned:

2. Interest rate

2. Date borrowed

M-D-Y

2. In deferment / repayment:

3. Lender name:

3. Loan type:

3. Amount loaned:

3. Interest rate

3. Date borrowed

M-D-Y

3. In deferment / repayment:

Do you own a vehicle?

Yes

reset

Current worth:

Amount owed:

Monthly payment:

Do you intend to purchase a computer / tablet?

Yes

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What type of device will you purchase?

Laptop

Tablet

reset

Have you applied for any of the following military scholarships?

Air Force

Army

Navy

National Guard

Are you eligible for an Illinois Veterans Grant (IVG)?

Yes

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Have you applied for a National Health Service Corps Scholarship?

Yes

reset

If you have applied for a private scholarship, please enter the name of the scholarship:

Parent 1 last, first name:

Parent 1 street:

Parent 1 city:

Parent 1 state:

Parent 1 zip:

Parent 1 area code / phone:

Parent 1 employer:

Parent 1 occupation:

Parent 1 occupation city:

Parent 1 occupation state:

Parent 2 last, first name:

Parent 2 street:

Parent 2 city:

Parent 2 state:

Parent 2 zip:

Parent 2 area code / phone:

Parent 2 employer:

Parent 2 occupation:

Parent 2 occupation city:

Parent 2 occupation state:

Are you the first member of your family to attend college?

Yes

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If no, what other family members attended college?

Parents

Siblings

Did a parent graduate?

Yes

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Did a sibling graduate?

Yes

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Where you raised by a single parent for the majority of time from birth to age 18?

Yes

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Do you consider yourself to have been financially disadvantaged while growing up?

Yes

reset

If yes, please explain:

Expand

Do you consider yourself to have been educationally disadvantaged while growing up?

Yes

reset

If yes, please explain:

Expand

Which best describes the type of community in which you grew up?

City - population more than 100,100
Inner city - central part of city, densely populated and lower income
Suburban - resident area adjacent to a city
Town - population 50,000-100,000
Rural - county and / or farming area

City

Inner city

Suburban

Town

Rural

reset

Did you live in federally subsidized housing while attending elementary / secondary school?

Yes

reset

Did you receive federally subsidized lunches while attending elementary / secondary school?

Yes

reset

My parents are beneficiaries of public assistance:

Yes

reset

Which program(s)?

Both of my parents are deceased:

Yes

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Age at time of father's death:

Age at time of mother's death:

I come from a health profession shortage area of medically underserved community:

Yes

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What is your religious preference?

Racial self-description:

Ethnic self-description:

Hometown city:

Hometown county:

Hometown state:

Name of high school from which you graduated:

List your medical specialty interest in rank order

1.
2.
3.

**REMINDER: Upon submission of this application, you will be given a link to open a document that contains Required Statements and other forms. In order for this application to be considered complete, print and sign. Originals of these forms must be mailed to: SIU School of Medicine, Financial Aid Office, P.O. Box 19624, Springfield, IL 62794-9624. You may not fax the forms to us, as your original signature is required.

Mail the forms to: SIU School of Medicine, Financial Aid Office, P.O. Box 19624, Springfield, IL 62794-9624.

**If you would like a copy of this application, click the download pdf button after clicking on the submit button.

Date submitted

M-D-Y

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Financial Aid Application

Student Information

Permanent Address

Preferred Address

Schools Previously Attended

Previous Financial Aid

(List all educational loans. Include all federally guaranteed loans and non-federal, private loans for which you still have a ballance due. Submit additional page if necessary.)

Scholarship Applications

References

(If parent is deceased, enter deceased as their name and do not complete address fields. If parent is unemployed or retired, indicate so in Employer's name.)

Personal Factors Used to Determine Low-Interest Loan and Scholarship Eligibility

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