Community Service Award Application

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Ohio State University College of Medicine Community Service Award Application

Name:

Email:

Phone Number:

Class Year: 2010 or 2011

Please list any relevant community service activities with which you have been involved during your time at OSUCOM. These activities may or may not be directly related to work at OSUCOM.

Activity, Position

time period

(mo/yr – mo/yr)

hours

(per week)

hours

(total)

Which community service activity has given you the most personal satisfaction? Please explain. (125 words or less)

What role will community service play in your future as a physician? (250 words or less)

Why would you recommend community service to your colleagues? (125 words or less)

Have you ever been placed on probation (academic or otherwise) by the OSUCOM? Y/N If yes, please explain:

By signing below, I verify that information provided on this application is correct (May be typed):

signature of applicant:

date: