Essay Contest Application Form If you are a human and are seeing this field, please leave it blank. First Name Last Name Address 1 Address 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto Rico Zip / Post Code Phone Email School/ Institution Name Year in School 1234 Attach your essay Do not include your name or school name anywhere within the essay document. Terms and Conditions By submitting my essay I signify that I agree to the Arnold P. Gold Foundation Essay Contest terms and conditions: I am committed to protecting the right to privacy of patients and others. I have changed names where applicable, and have omitted or altered other identifying characteristics of individuals and contexts within my essay. I grant The Arnold P. Gold Foundation permission to publish all or parts of my essay on their website, in the Academic Medicine or other academic journal and in other venues to promote the Essay contest. I signify that I am the sole author of this essay, that all sources of information have been properly acknowledged, and that it has not been published elsewhere.