On-Line Medical Bursary Application

Medical Student Bursary Application Form
Sponsored by the Brant County Medical Association and the Community Task Force on Primary Care

200 Terrace Hill Street, Brantford, Ontario N3R 1G9, Telephone 519-751-5544, Facsimile 519-751-5575

Personal Information:

Applicant Name:
Address:
Home Phone:
Home Fax:
Hometown
Secondary School
Medical School
E-mail:

Current Status (Select One): Year 1 Year 2 Year 3 Year 4

Graduation Date:

Clinical Interests: (Please list your top three areas of clinical interest)

Please note: A cover letter and a letter from the medical school stating that the aplicant is a medical student in good standing must accompany your application. It can be emailed to apreston@bchsys.org or sent by standard mail Attention: Brittany Timothy to the address listed at the top.

Leisure Interests/Hobbies:

ANNUAL HOUSEHOLD INCOME
A. Expected Personal Earnings
B. Expected Earnings of Spouse
C. Expected Parental Assistance
D. Cash on hand
E. Scholarships / Other Bursaries
F. Expected Student Loans
G. Other Income - Please specify



Total Annual Income:

ANNUAL HOUSEHOLD EXPENSES
a. Tuition
b. Books & Subscriptions
c. Rent/Mortgage
d. Utilities
e. Telephone-Internet
f. Food
g. Clothes/Laundry & Cleaning
h. Insurance (Life/Medical/Dental)
i. Transportation Expenses
j. Recreation
k. Personal Expenses
l. Other (please specify)


Total Estimated Annual Expenses

BUDGET SUMMARY
Total Income (A)
Total Expenses (B)
Estimated Deficit (A-B=C)

Total Accumulated Student Loans/Outstanding Credit Balance to date

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