Koch Kellan Application Form 2020 by Amber Quaid

KOCH KELLAN SCHOLARSHIP APPLICATION FORM 2020 Award Cycle Application Deadline: February 16, 2020

Application Instructions 1. Review the Koch Kellan Scholarship Guidelines for eligibility criteria, application timeline, and the full list of required application materials. 2. Complete all items on this application form (print or typed only). If the application form is incomplete, inaccurate, or not signed, the application will not be considered. 3. The application form and required application materials must be postmarked by February 16, 2019. If desired, the application form and essay may be uploaded at KochKellan.com. Your application is not considered complete until all materials are received by Paragon BioTeck, Inc.

Declarations (Initial each item below) I affirm that I am a third-year (Class of 2021) student with full-time status at an accredited graduate medical (MD) program within the United States. I affirm that I plan to pursue a clinical, teaching, and/or research career in ophthalmology. I release to Paragon BioTeck, Inc., the right to access my academic records, transcripts, and other information requested as provided by the officials of my institution. I waive my right to gain access to the letters of recommendation submitted on my behalf once they are received by Paragon BioTeck. If selected as the Koch Kellan Scholar, I release to Paragon BioTeck, Inc., the right to use my name and institution, photos, written content, and other materials for reports, press releases and other marketing and promotional purposes related to the Koch Kellan Scholarship without compensation. If selected as the Koch Kellan Scholar, I agree to attend the 2020 American Society of Cataract and Refractive Surgery Annual Meeting in Boston, Massachusetts, May 15-19. Travel and accommodations provided by Paragon BioTeck, Inc.

Signature and Disclaimer I, ________________________________________, have read and understand the conditions of the Koch Kellan Scholarship as explained in the current Koch Kellan Scholarship Guidelines. I affirm that this application, including the essay, is my own work, and that all the information contained herein is true and accurate to the best of my knowledge and grant permission for the information contained herein to be shared with the Koch Kellan Scholarship Review Committee.

Signature:

Date:

1. Application Information: Permanent Residence:

Last Name

First Name

Apt/Unit #

Street Address

City

Mobile Phone:

M.I.

State

Home/Alternate Phone:

Area Code + Phone Number

Zip Code

Area Code + Phone Number

Email Address:

2. Medical School Information: Medical School Address:

Medical School Name

Floor/Suite/Room #

Street Address

City

State

Expected Date of Graduation:

Zip Code

Official Academic Transcript Requested

3. Undergraduate School Information: Undergraduate School Location:

Date of Graduation:

City

Undergraduate School Name

State

Official Academic Transcript Requested (optional)

4. Relevant Coursework: Describe the three most significant courses you have taken in preparation for your career

5. Academic Activities: List up to 8 activities in descending order of significance; indicate dates and activity-related achievements. Examples include research, student government, publications, school-sponsored community service programs, and student-faculty committees.

1. Academic Activity, Date(s), Significant Achievement

2. Academic Activity, Date(s), Significant Achievement

3. Academic Activity, Date(s), Significant Achievement

4. Academic Activity, Date(s), Significant Achievement

5. Academic Activity, Date(s), Significant Achievement

6. Academic Activity, Date(s), Significant Achievement

7. Academic Activity, Date(s), Significant Achievement

8. Academic Activity, Date(s), Significant Achievement

6. Public Service and Community Activities: List up to 6 activities in descending order of significance; indicate role and dates. Do not repeat items. Examples include homeless services, environmental protection/conservation, advocacy activities, and work with religious organizations.

1. Public Service/Community Activity, Date(s), Role

2. Public Service/Community Activity, Date(s), Role

3. Public Service/Community Activity, Date(s), Role

4. Public Service/Community Activity, Date(s), Role

5. Public Service/Community Activity, Date(s), Role

6. Public Service/Community Activity, Date(s), Role

7. Employment: List part-time and full-time jobs/internships; include position title, description of work, employer, and dates. I have attached a CV or Résumé outlining my previous employment and internship details in lieu of completing the details below.

I have attached additional pages describing employment experience not listed below.

1. Position, Description, Employer, Date(s)

2. Position, Description, Employer, Date(s)

3. Position, Description, Employer, Date(s)

4. Position, Description, Employer, Date(s)

5. Position, Description, Employer, Date(s)

8. Awards and Recognitions: List awards, scholarships, publications, or special recognitions in descending order of significance. I have attached a CV or Résumé outlining award and recognition details in lieu of completing the details below.

I have attached additional pages describing award and recognition details not listed below.

1. Award, Publication, Date(s)

2. Award, Publication, Date(s)

3. Award, Publication, Date(s)

4. Award, Publication, Date(s)

5. Award, Publication, Date(s)

9. Government Activities: List government activities; indicate role and dates. Examples include partisan political activities, ROTC/military, municipal boards and commissions.

I have attached a CV or Résumé outlining government activity details in lieu of completing the details below.

I have attached additional pages describing government activity experience not listed below.

1. Government Activity, Role, Date(s)

2. Government Activity, Role, Date(s)

3. Government Activity, Role, Date(s)

4. Government Activity, Role, Date(s)

5. Government Activity, Role, Date(s)

9. Essay: Your essay, which is not to exceed 1,000 words, will be reviewed by the Scholarship Review Committee and will focus on the following topics: Why are you pursuing a career in ophthalmology? How does your academic interests and activities (coursework, interdisciplinary or independent study) serve as a foundation for your career? How does your background and future career goals align with the Paragon BioTeck, Inc., Vision Statement: “Drive innovations to address unmet and underserved medical needs and improve the quality of lives around the world?” I have attached an essay in lieu of providing the information below.