Aspirus Scholars Program Application

Aspirus Scholars Program Application
Thank you for your interest in the Aspirus Scholars Program scholarship opportunity. This is an online savable application which must be completed and submitted by 5 pm on September 30, each year.

You can save your progress at anytime using the button at the bottom of the application. If you wish to finish this application, save your progress and you can return to your application at any time and pick up where you left off using the link that was emailed to you.
I am currently enrolled in the Medical College of Wisconsin - Central Wisconsin Campus (MCW-CW):

YesNo
Thank you for interest in the Asprirus Scholarship Program. This program is only available to students enrolled in the Medical College of Wisconsin - Central Wisocnsin Campus (MCW-CW).

Employment History

Fill in at least one, and up to three previous positions from your employment history.
Name of Company (Experience 1)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title*
Job Responsibilities*
Supervisor Name*

First NameLast Name
Date worked from:*

MonthDayYear
Date
Date worked to:*

MonthDayYear
Date
Reason for leaving:
Name of Company (Experience 2)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Job Responsibilities
Supervisor Name

First NameLast Name
Date worked from:

MonthDayYear
Date
Date worked to:

MonthDayYear
Date
Reason for leaving:
Name of Company (Experience 3)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Job Title
Job Responsibilities
Supervisor Name

First NameLast Name
Date worked from:

MonthDayYear
Date
Date worked to:

MonthDayYear
Date
Reason for leaving:

Personal Statements
What field in medicine is going to give you the greatest satisfaction? How do your strengths relate to that field?*
Why would you choose to practice at Aspirus versus another health care system?*
When you consider where you would like to live following graduation/training, what attributes in a community are important to you? *
Share a personal example that demonstrates your commitment to passion for excellence and compassion for people.*

Preferred Practice Locations
Rank the geographic locations you would be most interested and willing to practice in order of your preference.

1 = most desired, 3 = least desired.
0 = any locations you are not willing to practice.
Wisconsin
Antigo Area *
Please indicate Rank
Medford Area*
Please indicate Rank
Northern Region (Eagle River, Tomahawk, Rhinelander and Woodruff)*
Please indicate Rank
Southern Region (Plover, Portage, Stevens Point and Wisconsin Rapids)*
Please indicate Rank
Central Region (Wausau and Merrill)*
Please indicate Rank
Upper Peninsula of Michigan
Ironwood Area*
Please indicate Rank
Iron River Area*
Please indicate Rank
Laurium Area (Keweenaw Peninusla)*
Please indicate Rank
Minnesota
Duluth Area*
Please indicate Rank
Two Harbors Area*
Please indicate Rank

Other Connections to Aspirus
Please indicate if you are currently or previously connected with Aspirus through any of the following positions:*

VolunteerStudentInternEmployeeNo ConnectionOther

Disclosures
Is your family member* employed by Aspirus, a physician employed by Aspirus, or a current board member of an Aspirus entity?*

YesNo
Name of Family Member

First NameLast Name
Relationship
* A “Family Member” means a husband or wife, birth or adoptive parent, child, or sibling, stepparent, stepchild, stepbrother, or stepsister, father-in-law, mother-in-law, daughter-in-law, grandparent of grandchild or spouse of a grandparent or grandchild.

You have an ongoing obligation to notify us of any changes to this disclosure (e.g., a Family Member accepts employment with Aspirus).
Signature
By my signature below, I hereby authorize any department of Aspirus that maintains all or any part of my records or personnel file to release such records to the Aspirus Recruitment Department.

I further fully discharge and release Aspirus from any and all liability for the reproduction and disclosure of my records and/or personnel file pursuant to this authorization.

I further certify that my answers are true and complete.

I understand that any false or misleading information in my application or interview may result in my disqualification from future employment with Aspirus and, if I am accepted to participate in the Aspirus Scholars Program, may cause the entire outstanding balance of any Scholarship disbursed to me under the Aspirus Scholar Program, to become immediately due and payable.
Signature

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Student Information