Name *

First Name

Last Name

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I hereby certify that the information I have provided on this application form and in any attached materials is true and complete. By checking the box below I certify that the information I am submitted is true and complete. I understand my personal information may be reviewed by individuals on the scholarship committee at the American Association of Black Physician Scientists (AABPS) and hereby give the law firm my full consent and permission to share my personal information and documents with those individuals and entities. I further understand that AABPS will aim for full privacy of submitted materials but cannot guarantee the privacy of any information or documentation submitted through its website and I hereby waive my rights to privacy with respect to all information submitted. I agree to hold the AABPS and its agents harmless for any and all potential injury and claims related to my personal information in the past, present, and future. I hereby give AABPS permission to share my personal information with public if I am awarded the scholarship and I understand that the awarded funds must be used for The American Medical College Application Service (AMCAS) applications and/or secondaries if I am the recipient of the scholarship.