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Application for Admission 2010-2011

Application for Admission 2010-2011

A nonrefundable application fee of $160 is required.This deposit is not an additional fee; it is applied to the cost of the program and it is refundable only if the student is not accepted into the University or if the program is canceled.
* All fields are required
If all fields are completed correctly, after you click "Submit" you will be redirected to the "Confirmation Page".
If you are not taken to the confirmation page, please check any error messages on the application.
Applicant Information
Full Legal Name
First Last Middle

Date of birth / MM / DD YYYY
Place of birth

city / state / country
Nationality
Sex Female Male
Marital status Married Single

Contact information
Current address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Home phone - (###) - ### ####

Cell phone - (###) - ### ####
Email address
Permanent Contact Information (Parent/Friend/Guardian)
Name First Last

Relationship
Home phone (Parent/Friend/Guardian) - (###) - ### ####

Email address (Parent/Friend/Guardian)

Education options
Specialization Medicine Dentistry Pharmacy

Accommodation Shared apartments Student dormitories Living with a host family

Language
Native language
Foreign language

Proficiency in foreign languages

Please, fill in as appropriate : excellent, good, poor Ex: Spanish-excellent German-good

Academic Information
1. High School education
Name of High School attended
Date of Admission / MM / DD YYYY

You can approximate!
Date of Completion / MM / DD YYYY

You can approximate!
Have you taken the ACT exam? YES NO

If "YES"what was the Composite Score? If "NO" type "N/A"
Have you taken the SAT exam? YES NO

If "YES"what was the Composite Score? If "NO" type "N/A"
Student’s cumulative GPA (High School)
2. College/University
CURRENT CLASSIFICATION Undergraduate Student Graduate Student Professional Other
Select "Other" if you have not attended a college/university

CLASS STANDING Freshman Sophomore Junior Senior None of the above
Select "None of the above" if you have not attended a college/university

Student's cumulative GPA(College)

3. Coursework
Summary of academic courses you have taken starting with 9th grade. Biology Chemistry I Chemistry II Organic Chemistry Physics Anatomy Pre-Calculus Calculus

List the AP (advanced placement) courses you have taken.

Type "none" if you have not taken any AP courses.
4. Activities
List the activities you are involved in outside of the classroom in the order of the time you spend on each activity.

Volunteer work, Sports, Special projects, etc.
Student's Statement
Have you ever been expelled or placed on academic probation? NO YES

Have you ever been convicted of a criminal offense? NO YES

Payment options
Payment Check Money order PayPal

By submitting this form I certify that the statements I have made on this application are correct and complete. I understand that withholding information requested on this application or giving false information will make me ineligible for admission to Medical School, or subject to dismissal.
Today's Date / MM / DD YYYY

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