Leadership Award Application

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Ohio State University College of Medicine Leadership Award Application

Name:

Email:

Phone Number:

Class Year: 2010 or 2011

Please list any relevant leadership 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.

Leadership Activity, Position

time period

(mo/yr – mo/yr)

hours

(per week)

hours

(total)

Which leadership role has given you the most personal satisfaction? Please explain. (125 words or less)

Why do you feel leadership experience is essential for your personal and professional fulfillment? (250 words or less)

How do you encourage others to seek leadership roles? (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: