First name:
* must provide value
Last name:
* must provide value
Birthday:
* must provide value
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Birthplace (city/state):
* must provide value
Email address:
* must provide value
Marital Status:
* must provide value
Single Married Divorced/Seperated Widowed
Number of Children:
* must provide value
Citizenship status:
* must provide value
U.S. citizen
Naturalized citizen
Permanent resident
Date of naturalization:
* must provide value
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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
No
Preferred area code / phone #
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State or private lender not federally guaranteed Direct subsidized Stafford Direct unsubsidized Stafford Federal subsidized Stafford Federal unsubsidized Stafford Direct subsidized consolidated Direct unsubsidized consolidated Federal subsidized consolidated Federal unsubsidized consolidated Federal Perkins Loan Direct PLUS Federal PLUS Direct GRAD PLUS Federal GRAD PLUS Health Professions Student Loan for disadvantaged student Nursing student
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In deferment / repayment:
Deferment Repayment
State or private lender not federally guaranteed Direct subsidized Stafford Direct unsubsidized Stafford Federal subsidized Stafford Federal unsubsidized Stafford Direct subsidized consolidated Direct unsubsidized consolidated Federal subsidized consolidated Federal unsubsidized consolidated Federal Perkins Loan Direct PLUS Federal PLUS Direct GRAD PLUS Federal GRAD PLUS Health Professions Student Loan for disadvantaged student Nursing student
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2. In deferment / repayment:
Deferment Repayment
State or private lender not federally guaranteed Direct subsidized Stafford Direct unsubsidized Stafford Federal subsidized Stafford Federal unsubsidized Stafford Direct subsidized consolidated Direct unsubsidized consolidated Federal subsidized consolidated Federal unsubsidized consolidated Federal Perkins Loan Direct PLUS Federal PLUS Direct GRAD PLUS Federal GRAD PLUS Health Professions Student Loan for disadvantaged student Nursing student
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3. In deferment / repayment:
Deferment Repayment
No
Yes
Do you intend to purchase a computer / tablet?
No
Yes
What type of device will you purchase?
PC
Laptop
Tablet
Have you applied for any of the following military scholarships?
Are you eligible for an Illinois Veterans Grant (IVG)?
No
Yes
Have you applied for a National Health Service Corps Scholarship?
No
Yes
If you have applied for a private scholarship, please enter the name of the scholarship:
Parent 1 last, first name:
Parent 1 area code / phone:
Parent 1 occupation city:
Parent 1 occupation state:
Parent 2 last, first name:
Parent 2 area code / phone:
Parent 2 occupation city:
Parent 2 occupation state:
Are you the first member of your family to attend college?
No
Yes
If no, what other family members attended college?
No
Yes
No
Yes
Where you raised by a single parent for the majority of time from birth to age 18?
No
Yes
Do you consider yourself to have been financially disadvantaged while growing up?
No
Yes
Do you consider yourself to have been educationally disadvantaged while growing up?
No
Yes
Did you live in federally subsidized housing while attending elementary / secondary school?
No
Yes
Did you receive federally subsidized lunches while attending elementary / secondary school?
No
Yes
My parents are beneficiaries of public assistance:
No
Yes
Both of my parents are deceased:
No
Yes
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:
No
Yes
What is your religious preference?
African-American Asian or Pacific Islander Caucasian Chinese Cuban Filipino Hispanic / Other (Spanish, Latino) Indian or Pakistani Japanese Korean Mexican-American Puerto Rican Vietnamese
Name of high school from which you graduated:
List your medical specialty interest in rank order
**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.
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