Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application

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1 Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application Date of Application: LMU ID # (if applicable): Name Last First Middle Preferred Name Social Security Number - - Male Female Date of Birth Mailing Address Street City State Zip Telephone County (Area Code) Where is your permanent residence: State County What is your country of citizenship? United States : please specify If you are not a US citizen, what is your visa status? Permanent Resident Temporary: please specify I currently do not have a valid U.S. visa. High School Attended: School Graduation date Higher Educational Institutions attended: Dates attended Major Degree earned 1

2 Graduate Record Examination (GRE) Scores Date(s) Verbal Reasoning / Quantitative Reasoning / Critical thinking and analytical writing / / / / Please list any honors or awards you have received. Please list any training certifications. What is the population of your hometown? 1,000,001 or more 10,001 to 50, ,001 to 1,000,000 5,001 to 10, ,001 to 500,000 2,500 to 5,000 50,001 to 100,000 Fewer than 2,500 Please describe your professional experiences. 2

3 Please describe significant volunteer experiences. Military experience: If, yes, was your discharge honorable? Branch of service: Have you previously attended a physician assistant or medical program? If Yes, please specify program Please explain reason for leaving program? Were you ever disciplined for academic performance or conduct violations (e.g. academic probation, dismissal, suspension, disqualifications, etc.) by any school or college? If yes, please explain. Have you ever been convicted of a felony or misdemeanor? If yes, please list and date. How did you hear about Lincoln Memorial University - DeBusk College of Osteopathic Medicine s PA program? Pre-professional advisor D.O. / M.D. PA Osteopathic Medical College Media (TV, Radio, Print) AAPA TAPA Professional Organization Recruitment Mailing Internet 3

4 Please list any relatives who have attended Lincoln Memorial University. Name Relationship Class Name Relationship Class Name Relationship Class Name Relationship Class Statement of Past or Pending Disciplinary Action Name of Applicant: Date: Have you ever been subject to revocation of a professional license, or been censured, reprimanded or placed on probation for reasons relating to professional competence or conduct by a state licensing authority? If Yes, please explain. Have you ever had disciplinary action taken against you by any professional society or professional association? If Yes, please explain. Have you ever been treated for problems with alcohol or drug dependency? If Yes, please explain. Is there any information relevant to your ability to complete the Lincoln Memorial University DeBusk College of Osteopathic Medicine Physician Assistant program and be certified for licensure that LMU-DCOM should consider? (Please review the DCOM-PA Program Technical Standards before answering.) If Yes, please explain. 4

5 Prerequisite courses need to be completed with a grade of "C" (we do not accept prerequisite courses with a grade of C-, D, or F ) or better from a regionally accredited college or university: Please check the following for each pre-requisite course required by the program. Complete In Progress Haven t Started - General Biological Science with laboratory (two semesters, eight to ten semester hours or equivalent) - Human Anatomy with lab and Human Physiology (separate courses of at least three to four semester hours each), or a combined anatomy and physiology course with lab, at least two semesters - General Chemistry with laboratory (two semesters, eight to ten semester hours or equivalent) -Organic Chemistry with laboratory (four to five semester hours) -Biochemistry (three to four semester hours) or a second semester of Organic Chemistry with laboratory (four to five semester hours) - General Psychology (three semester hours or equivalent) - Psychology elective (three semester hours or equivalent) - Microbiology with lab (four to five semester hours or equivalent) -English (six semester hours or the equivalent with at least one writing intensive course, such as English composition) - Mathematics (three semester hours or equivalent of college algebra or higher) - Medical Terminology (one semester) (Online courses from an accredited college or university are acceptable for Med Term) CERTIFICATION I certify that all information provided on this application is true and accurate, complete and correct to the best of my knowledge and belief, and is made in good faith. I know and understand that any and all items contained herein are subject to verification and I consent to the full release of all information concerning my capacity and fitness for the educational program by employers, educational institutions and other agencies. I agree that providing inaccurate or false information or that failure to comply with University policy may result in disciplinary action, including dismissal. Throughout my enrollment, I agree to comply with the rules and regulations in the Lincoln Memorial University-DeBusk College of Osteopathic Medicine Physician Assistant student handbook. Finally, I authorize the people named on my LMU-DCOM Physician Assistant Program Application to provide an evaluation about my academic performance and/or nonacademic experience relative to my potential for becoming an effective Physician Assistant. Signature of Application Date I have enclosed a $50.00 non-refundable application fee. I have included an updated resume. Please return to: LMU-DCOM, Physician Assistant Program, Office of Admissions and Student Advancement, 6965 Cumberland Gap Parkway, Harrogate, TN

Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application

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