Submission Guidelines:

Your application, two recommendation forms, and the Certification of Education Status must be postmarked by

December 14, 2018. Awards will be made in March.

Please send the entire completed application by the deadline to:

April L. Vestal, MPH, Director

WVU Institute for Community and Rural Health

PO Box 9009

Morgantown WV 26506-9009

Dental Scholarships are awarded through a competitive process, so please provide complete information. You may attach additional pages if needed. Please type or print your responses in blue ink.

You can obtain an application form by visiting http://www.hsc.wvu.edu/icrh/Students and clicking on Dental Scholarship Program.

The following materials are enclosed:

* Dental Scholarship Program Student Application

* Recommendation form

* Certification of Education Status Form

* Eligible Sites for Service Obligation

Eligibility:

Fourth year dental students at West Virginia University School of Dentistry, who intend to practice in West Virginia. Selected students will receive a $50,000 scholarship in exchange for a 24-month commitment for full-time work in WV.

Obligation to Practice in West Virginia:

Students who are awarded a scholarship must sign a contract and practice full-time (32-40 hours per week) for a minimum of one year at an eligible site. Preferred geographic areas eligible for the service obligation are shown on the Dental Health Professional Shortage Areas (http://hpsafind.hrsa.gov).

In order to locate dental HPSAs on the website, choose WV as the state, then choose the county in which you are interested. Under discipline, choose “dental” and click the button “show me the HPSAs”. If you have any questions regarding the website or dental HPSAs, please contact Dr. Meckstroth or the WVU Institute for Community and Rural Health.

Students are responsible for locating a practice site and must agree to provide oral health services to West Virginia Medicaid and CHIP recipients. The penalty for not fulfilling the service obligation is repayment of the scholarship with 15% interest.

Eligibility for Other Financial Incentives:

Students who are awarded a Dental Scholarship also may qualify for other financial incentives for rural practice in West Virginia. In some cases, the service obligations can be met concurrently.

If you have any questions, you may discuss the program with Dr. Richard Meckstroth or:

April L. Vestal, MPH, Director

West Virginia Institute for Community & Rural Health

PO Box 9009

Morgantown WV 26506-9009

Phone: (304) 276-0920

Fax: (304) 293-8764

Email: avestal@hsc.wvu.edu

Name:	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Date of Birth:	Click or tap to enter a date.
Current Mailing Address:	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Evening/Home Phone:	Click or tap here to enter text.	Cell Phone:	Click or tap here to enter text.
Email Address	Click or tap here to enter text.
Permanent Mailing Address: (Check if same as above)	☐	Click or tap here to enter text.
Current Year in School:	Click or tap here to enter text.
Anticipated Graduation Date:	Click or tap here to enter text.
Career Goal:	Click or tap here to enter text.
Are you a resident of WV?	Choose an item.
If yes, how many years?	Click or tap here to enter text.
What is your home County?	Click or tap here to enter text.
Please provide complete information in your responses. Attach additional pages if necessary.
Background: Where were you born and raised? What family ties, if any do you have in rural West Virginia? Have you ever lived or worked in rural West Virginia or another rural area/state?
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What personal and professional attributes make you a good match for rural practice?
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What do you believe to be the positives and negatives of practicing and living in West Virginia?
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If you received this scholarship, what impact would the service obligation have on your personal life?
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Describe any related community research, service projects or volunteer work you have done in rural West Virginia.
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Have you explored practice opportunities in West Virginia?
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If yes, where? Click or tap here to enter text.
Do you have a geographic preference?
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Comments?
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Do you have any professional or personal barriers to relocating to any part of the state?
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Do you have any other service obligations, including military obligations?
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If yes, please describe.

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Students who receive financial assistance funded by State revenue must be in compliance with the Selective Service Act which requires that males between the ages of 18 and 25 register with the Selective Service. Are you in compliance?

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Comments: Click or tap here to enter text.

List a minimum of three practice opportunities you have explored, including the site and location. If you have not yet explored any options, indicate any areas (counties, towns) you may be considering.

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Did you grow up in or near any of the above communities?

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Additional Application Materials Required for All Applicants:

In addition to submitting a completed copy of this application, all applicants must also submit the following forms to the School of Dentistry Scholarship Committee. All materials must be postmarked by December 14, 2018:

Your completed scholarship application should include:

The completed 2018-19 WVU Institute for Community and Rural Health Student Application Form.

At least two letters of recommendation (use the linked Recommendation form) from (1) an official in the Dean’s Office who can address your academic work, clinical skills and professionalism, and (2) An individual (not a relative) who is knowledgeable about your clinical experiences as a health professions student.

Letters of recommendation may be mailed separately, but must be submitted by the deadline.

A completed version of the enclosed Certification of Educational Status Form executed by yourself and the appropriate school official.

*Please notify Dr. Richard Meckstroth that you are applying for the scholarship.

I hereby certify that all the above statements are true and correct. I understand that, if I am awarded a Dental Scholarship, I am obligated to practice a minimum of one to three years (depending on the amount of the award) in a rural, underserved area of West Virginia or other eligible sites upon graduation. Preferred geographic areas eligible for the service obligation is any site designated a dental health professions shortage area. I understand that these designations frequently change.

I understand it is my responsibility to locate a practice site and be prepared to meet with the scholarship committee to explain why I selected the site.

I also understand that false statements on this application may be grounds for breach of contract.

_________________________________

(Signature of Applicant)	Date: Click or tap to enter a date.