SCHOOL OF MEDICINE MEDICAL ETHICS APPLICATION FOR ADMISSION

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1 Personal Information SCHOOL OF MEDICINE MEDICAL ETHICS APPLICATION FOR ADMISSION Name The information you enter here will be printed and evaluated exactly as you have typed it. Do not use all upper case or all lower case letters. / / Last (family) Name First (given) Name Middle Former name(s) or name under which your academic records may have been stored, if different from above. / / Last (family) Name First (given) Name Middle Date of Birth / / Month Day Year Place of Birth City State OR Country Gender Male Female Other Marital Status Married Single What is your United States citizenship/residency status? (Please check only one box.) U.S. citizen Permanent U.S. Resident (Green Card) Temporary Alien (Non-Resident) If your answer to the above question is Temporary Alien (Non-Resident), please indicate your visa status: I already have a temporary visa I need to acquire a temporary visa Of what country (countries), other than the United States, are you a citizen? If you are not a US citizen or Permanent Resident, you must complete the International Applicant Financial Affidavit form and International Sponsor Affidavit form. These forms can be downloaded from New York Medical College s website.

2 Ethnicity & Race The information requested listed below is optional. The questions are asked because NYMC is subject to certain recordkeeping and reporting requirements. Are you Hispanic or Latino? Yes No What is your race? (Select one or more of the following five categories) Contact Information American Indian or Alaska Native Arab or Middle Eastern or North African Asian Black or African American Native Hawaiin or Pacific Islander White Other, if so Current Mailing Address All correspondence will be directed to this address. This address is effective until: Address Line 1 Address Line 2 Address Line 3 City State County (NY State only) Postal Code Country Phone Number Please indicate with an X your preferred phone number. Home/Evening Work/Daytime Cell Phone address: Please note that applicants should maintain a valid address during the entire application process. Most of our correspondence will be through . Have you ever been convicted of a felony or misdemeanor? Yes No If yes, please explain on a separate sheet of paper.

3 Previous Education You are required to submit transcripts from all colleges, professional schools and universities attended (including New York Medical College). If your transcripts are from an institution in the U.S. or Canada, we strongly recommend sending an unofficial copy of your transcripts with this application in addition to having official copies sent. The Office of Admissions will use unofficial copies of transcripts for admission consideration. Candidates offered admission will later be required to supply official documents prior to enrollment before the offer is considered official. If your postsecondary credentials are from an institution outside the U.S. or Canada, the Office of Admission will not review unofficial documents for admission consideration; you must submit a certified English credential evaluation and translation for all postsecondary institutions attended. Below, please list the school where your bachelor s degree was, or will be, conferred first and any additional undergraduate, postsecondary degree, or nondegree education in the remaining sections. If additional space is needed, please attach a separate sheet of paper. Name and Location of School (City, State and Country) (List schools in chronological order) Dates of Attendance (From/To) (mm/dd/yyyy) Type of Degree (B.A., B.S., etc.,) Date Degree Awarded or Date Degree Expected (mm/dd/yyyy) Major Minor Overall GPA (x.xx) GPA in Major (x.xx) GPA should be calculated according to the following table: Letter A+ A A- B+ B B- C+ C C+ D+ D F (97-100) (93-96) (90-92) (87-89) (83-86) (80-82) (77-79) (73-76) (70-72) (67-69) (65-66) (below 65) GPA

4 Previous Employment / Volunteer Experience Below, please list your previous employment/volunteer experiences. If additional space is needed, please attach a separate sheet of paper. This can be included as part of your CV. Employer/Volunteer Experience (List most recent experience first) Start and End Dates mm/dd/yyyy Hrs/Wk Job Title/ Briefly describe your responsibilities Has there been any significant interruption in your education or work? Yes No If yes, please specify On a separate sheet of paper, please list publications, academic and professional honors, awards, licenses. This can be included as part of your CV. Please check this box if you are submitting a list of publications, etc.

5 Application Information How did you hear about this program? What attracted you to this program? (50 words or fewer) Why are you pursuing an advanced degree / certificate in this field? (50 words or fewer) Are you currently applying to another program at New York Medical College? Yes No If yes, please specify Have you previously applied to any of the following NYMC schools: NYMC s School of Medicine Result NYMC s Graduate School of Basic Medical Sciences Result NYMC s School of Health Sciences and Practice Result Have you ever been the recipient of any institutional action resulting from unacceptable academic performance or a conduct violation (even if such action did not interrupt your enrollment, require you to withdraw, and/or does not appear on or has been deleted from your official transcripts due to institutional policy or personal petition)? Yes No If yes, please submit your statement of the circumstances on a separate sheet of paper.

6 Are you currently serving in the United States military? Yes No Are you a U.S. veteran? Yes No List the names of two (2) individuals who will be submitting letters of recommendation on your behalf. Would it be possible for you to visit New York Medical College for an interview? Yes No Would it be possible for you to interview via Skype? Yes No If yes, please provide your Skype address:

7 Self-Reported Test Scores Please list test scores relevant to your application in the section below. We strongly recommend sending an unofficial copy of your test scores with this application in addition to having official copies sent. For MCAT, print your scores with your AAMC ID number and verification code from the AAMC website and or fax the score report to the GSBMS Office. The Office of Admissions will use unofficial copies of test scores for admission consideration. Candidates offered admission will later be required to supply official documents prior to enrollment before the offer is considered official. GRE Date Test was Administered (mm/dd/yyyy) Verbal Quantitative Analytical Writing GMAT Date Test was Administered (mm/dd/yyyy) Verbal Quantitative Total Score Score Analytical Writing

8 LSAT Date Test was Administered (mm/dd/yyyy) Raw Score Score Scaled Score Score MCAT Date Test was Administered (mm/dd/yyyy) Verbal Reasoning Physical Sciences Writing Sample Biological Sciences

9 Statement of Purpose On a separate sheet of paper, please address the following ( words): 1. Your purpose and interest in pursuing a degree in medical ethics. 2. How the degree program fits into your overall professional growth, focusing in particular on the connection between the program and your academic and/or professional experience. Contact Information for Application Inquiries Program in Biomedical Ethics & Humanities New York Medical College 19 Skyline Drive, GN B14 Hawthorne, NY Phone: (914) Office hours: Monday-Thursday, 9 a.m. 5 p.m.

10 A $75.00 non-refundable application fee payable to New York Medical College by check must be submitted with this application. Please mail the check to the address in the Contact Information. Former Master s students who are re-applying to New York Medical College must pay a $75.00 non-refundable application fee. All official postsecondary transcripts and test scores must be sent directly from the issuing institution or agency to the Office of Admissions. MCAT scores must be downloaded from the AAMC website; the applicant must or fax the MCAT verification code and AAMC ID listed on the score report to the Office of Admissions. Two letters of recommendation from professors or other professionals with knowledge of the applicant must be submitted. Letters of recommendation must be dated, signed, and written on the letterhead of the writer s institution and mailed directly by the writer to the Admissions Office in sealed envelopes. Two letters or forms from outside New York Medical College are required. Additional letters, including those from NYMC faculty, will also be accepted. Personal statements and CVs may be included in this application or sent as a separate attachment. Materials may be submitted either via to or mailed to the Program in Biomedical Ethics & Humanities. All materials must have the applicant s name on them, as well as the program and anticipated semester to which he or she is applying. All submitted materials become the property of New York Medical College and cannot be returned either as an original or a photocopy. New York Medical College is an Equal Opportunity and Affirmative Action Institution. No person shall be denied admission to any education program or activity on the basis of any legally prohibited discrimination involving, but not limited to, such factors as race, color, creed, religion, national or ethnic origin, sex, age or disability. Additionally, no person shall be discriminated against in the College's programs, activities and employment. All policies regarding admissions, employment and educational programs and activities are established and administered in conformity with the Education Practices Act of New York as well as applicable state and federal civil rights laws, specifically including Title IX of the Education Amendments Act of 1972, and with Section 504 of the Rehabilitation Act of 1973, as amended, and regulations thereunder prohibiting practices or policies in admissions, education programs, or employment that are in any way discriminatory on the basis of sex and disability, respectively. Any grievances pertaining to discrimination should be directed to Ira Bedzow, PhD, New York Medical College, (914) I certify that all my answers are complete and accurate to the best of my knowledge. I understand that New York Medical College reserves the right to deny admission or permission to register or to require the withdrawal of any person whom it considers deficient in scholarship, character or conduct. Signature of Applicant Date

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