PHARMACY COLLEGE ADMISSION TEST+ PROGRAM PROGRAM DATES: May 20, 2016 JULY 22, 2016

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1 PHARMACY COLLEGE ADMISSION TEST+ PROGRAM PROGRAM DATES: May 20, 2016 JULY 22, 2016 APPLICATION DEADLINE: 5:00 PM, FRIDAY, March 25, :00 PM, FRIDAY, April 8, 2016 The Pharmacy College Admission Test Plus (PCAT+) Program is designed for New Mexico residents preparing to take the PCAT and apply to the College of Pharmacy. This program provides test preparatory for students to become competitive applicants to pharmacy schools. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. PCAT+ students are expected to approach the experience with a commitment to scholarship and exploration. The PCAT+ Program will be located in Albuquerque, NM on the UNM Health Sciences Center campus. Interested applicants must be New Mexico residents, as defined by the UNM School of Medicine, Preferably, underrepresented in medicine and come from economically and/or educationally disadvantaged backgrounds. Applicants should demonstrate a commitment to increasing health equity. Applicants accepted in to our HEALTH NM pipeline programs must have a Social Security Number (SSN) or Individual Tax Identification Number (ITIN). Questions regarding citizenship, residency and/or application details can be directed to HSC-diversity@salud.unm.edu or by calling or toll free Eligibility Requirements Minimum GPA of 2.75 on a 4.0 scale NM resident currently enrolled in college as a junior, senior, or graduate General Biology I & II (1 academic year, 2 semesters) General Chemistry I & II (1 academic year, 2 semesters) Organic Chemistry I (1 academic year, 2 semesters) * Physics I & II (1 academic year, 2 semesters)* * If these courses have not been completed, please provide a plan that shows when you will fulfill these requirements. Participation Dates The program will begin on Friday, May 20, Student participants will be required to be on campus for the Kaplan course on Tuesdays and Thursdays from 6:00pm to 9:00pm (times may vary for full length practice exam), beginning on Tuesday May 24, 2016 and ending on July 7, All participants are expected to participate in the program Orientation on Friday May 20, 2016 and the Summer Program Graduation Ceremony on Friday July 22, Student participation is expected throughout the duration of the program. If accepted into the program, the Office for Diversity will send all participants an acceptance packet that must be completely filled out and returned to our office no later than Friday, May 13, Failure to include any of the supporting documents, not following directions completely, or leaving blank sections on this application form will result in an automatic disqualification. Additionally, failure to meet the April 8, 2016 deadline will result in automatic disqualification. To apply, please complete the attached application. ALL COMPLETED APPLICATIONS MUST BE SUBMITTED IN PERSON BY 5:00 PM OR POSTMARKED ON OR BEFORE MARCH 25, APRIL 8, FAXED APPLICATIONS WILL NOT BE ACCEPTED. SUBMIT COMPLETE APPLICATION BY MARCH 25, 2016 APRIL 8, 2016: Mail to: UNM College of Pharmacy MSCO University of New Mexico Albuquerque, NM Deliver in person to: UNM Health Science Center, UNM North Campus College of Pharmacy Nursing/Pharmacy Building, Room 188 Building #228, Campus Map PCAT+ Application Revised 3/22/16

2 PCAT+ PROGRAM PROGRAM DATES: May 20, 2016 JULY 22, 2016 APPLICATION CHECKLIST APPLICANT NAME: Complete application packets must include: Complete Student Application College Transcript(s): An unofficial transcript from all the schools that you have attended Resume PCAT test score report(s). (If taken, it is required to report previous scores. It is not a requirement to be registered or have previously taken the PCAT for the program.) Personal Statement: (The personal statement must be typed, double-spaced, 12-point font, Times New Roman, 1 margins, and no more than 2 pages.) Please state your purpose in applying to this program. In this personal statement we are seeking to capture not only a snapshot of where you are currently as a student but also where you have been and where you see yourself in the future as a health professional. Relevant factors include but are not limited to the following: Achievements you have accomplished in spite of educational, social, and economic challenges. What in your personal, work, or academic background has motivated your interest in a health career? What are your educational goals and how will they impact you, your family, and your community? What kind of educational experiences and skillset do you expect to gain this summer that will best assist you in reaching your career goals and dreams? Two Completed Recommendation Forms One form should be completed by someone who can evaluate your character and academic performance, such as a professor, teacher, counselor, principal, mentor, employer, or volunteer supervisor. The second form can be from someone of your choosing. Forms must be in a sealed envelope with the writer s signature across the seal on the back of the envelope. Office Use Only Date Submitted: Staff Initials: PCAT+ Application Revised 3/22/16

3 PERSONAL INFORMATION PHARMACY COLLEGE ADMISSION TEST+ (PCAT+) PROGRAM ALBUQUERQUE, NEW MEXICO STUDENT APPLICATION Please make sure that the information given in this section is accurate and matches with any federal or state issued document (ex. Social security card, ITIN card). 1. Name: Last First Middle 2. Address: Street Address or P.O. Box Number City or Town County State Zip 3. Phone: Address: 4. Gender: Female Male 5. U.S. Citizen: Yes No If no, can you provide a SSN or ITIN: Yes No 6. New Mexico Resident: Yes No If no, state of residency: 7. Date of Birth: 9. Place of Birth: 8. Do you consider yourself to be Hispanic/Latino(a)? Yes No In describing yourself, please select one or more of the following racial categories: American Indian or Alaskan Native (Specify affiliation): 9. What language(s) do you speak? Asian Black or African American Native Hawaiian/Pacific Islander White Other (Please specify): What is the primary language spoken at home? What was your first language? EDUCATIONAL BACKGROUND 10. Please list schools you are attending and/or have attended beginning with high school: High School: College: College: School Name City and State Dates of Attendance Cumul. GPA 11. Indicate your current year in college: Freshman Sophomore Junior Senior Graduate Please indicate anticipated or actual college graduation date: 12. Undergraduate Major/Minor: Graduate Program: 13. Overall GPA: 14. Please list general prerequisite courses that you have taken (indicate course numbers): *If you have completed these requirements, please provide (month/year) when you plan to complete them. General Biology: General Chemistry: General Physics: Organic Chemistry: Mathematics: English: 15. Have you taken the PCAT? Yes No If so, please list score(s) and date(s). (Please attach copy of PCAT score report.) 16. If not, please list the date you intend to take it: 2016 PCAT+ Application Revised 3/22/16

4 FAMILY BACKGROUND Parent/Guardian 1 (Required): Applicant lives with this parent/guardian: Yes 17. Name: No Last First Middle 18. Address: Street Address or P.O. Box Number City or Town County State Zip Code 19. Phone: Address: 20. Circle highest grade completed: Did your parent/guardian attend college? Yes No 22. Please check the highest level of degree obtained? Associate Degree Bachelor s Degree Master s Degree Doctoral Degree Other 23. Occupation: 24. Employer: Parent/Guardian 2 (Required): Applicant lives with this parent/guardian: Yes 25. Name: No Last First Middle 26. Address: Street Address or P.O. Box Number City or Town County State Zip Code 27. Phone: Address: 28. Circle highest grade completed: Did your parent/guardian attend college? Yes No 30. Please check the highest level of degree obtained? Associate Degree Bachelor s Degree Master s Degree Doctoral Degree Other 31. Occupation: 32. Employer: FINANCIAL BACKGROUND 33. I am currently financially supported by (check all that apply): Self Father Mother Other (state relationship to you): 34. Total Annual Household Income: 35. How many people live in your household (include yourself)? 36. Number of children or dependents in your household (include ages): ADDITIONAL INFORMATION 37. Do you have any relatives in a health profession? Yes No Which specific fields? 38. Have you completed any other UNM HSC Office for Diversity programs (select all that apply)? Dream Makers/Dream Makers + HCA USHEP STEAM-H Program Pre-College Science & Math Program 39. How did you find out about this program? Instructor/Advisor Web Publications (websites, listserv) 2016 PCAT+ Application Revised 3/22/16

5 Office for Diversity Friend/Parent Flyer/brochure Other (specify): 40. Please list your health career interest(s): 41. Please list any health related certifications or training you have received and date of completion (i.e. CPR, First Aid): 42. Please list extra-curricular, volunteer, and/or community experiences: (i.e. sports, school clubs, church activities, etc.) 43. Do you have any other obligation during the program Participation Dates that may interfere with your ability participate in this program? Yes No 44. If answered yes, please include information and dates for things such as (but not limited to), anticipated travel, employment, college orientation, etc. 45. If applicable, please list any special needs or considerations you would like us to be aware of: STATEMENT OF CERTIFICATION I certify that all information given is true to the best of my knowledge. I understand that failure to disclose accurate information is grounds for dismissal from or selection into the program Signature of Applicant Date PCAT+ Application Revised 3/22/16

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7 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name on the line below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Pharmacy College Admission Test + (PCAT+) Program. This program s purpose is to prepare students to take the PCAT by providing test preparatory for its participants so they can become competitive applicants to medical school. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Pharmacy College Admission Test + Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, April 8, How long and in what capacity have you known this applicant?

8 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)

9 RECOMMENDATION FORM PLEASE RETURN THIS WITH YOUR APPLICATION To the Applicant Please fill in your name on the line below and give this information to the individual you have selected provide a recommendation for you. Applicant s Name To the recommending individual The student named above is applying to the UNM Health Sciences Center, Office for Diversity s Pharmacy College Admission Test + (PCAT+) Program. This program s purpose is to prepare students to take the PCAT by providing test preparatory for its participants so they can become competitive applicants to medical school. This program will challenge student achievement by balancing a rigorous curriculum with academic, social, and developmental support. This program seeks to identify students who demonstrate the following characteristics: Financial need; Academic performance or promise; Interest in pursuing a health related career; Strength of character, evidence of leadership potential, and emotional maturity and stability; The potential to contribute to one s community later in life. Please provide your contact information below, in the case that the Office for Diversity staff has any pending questions or concern. Recommender Name: Phone Number: Relationship to Applicant: To help in the selection of participants into the Pharmacy College Admission Test + Program, we ask that you please answer all of the following questions. Please limit your answers to the allotted space provided. ALL COMPLETED RECOMMENDATION FORMS MUST BE SUBMITTED IN A SEALED ENVELOPE TO THE STUDENT PRIOR TO THE APPLICATION DEADLINE OF FRIDAY, April 8, How long and in what capacity have you known this applicant?

10 Please describe the applicant s strengths? Please comment on the applicant s area(s) of development. What efforts has the applicant made to improve? How has the applicant contributed above and beyond her/his expected responsibilities? Please use the following space to include any additional comments. (Optional) Please rate the applicant on the following categories: Cannot Recommend Below Above Excellent Academic Performance Leadership Qualities Emotional Maturity Reliability Ability to interact with adults and peer Professionalism Resiliency (Ability to overcome barriers)