Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Name *

School Guidance Counselor

First Name

Last Name

I will be a full-time college student in the Fall *

Yes

No

Checkbox *

By checking the box below, If selected, I understand that this is a $1,000 one-time gift to the university of my choice. All of the information provided above is correct. I am a resident of northwest Oklahoma and am interested in pursuing a career as a physician. I acknowledge that this application is due on March 31st. Checking this box is used as my digital signature of submitting this application

I Understand