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

Transcription

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 Other: 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. What is your racial identification? American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or other Pacific Islander White (non-hispanic) High School Attended: School Name City State Graduation date Higher Educational Institutions attended: Dates attended Major Degree earned Name City State Name City State Name City State 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 Are there any health-care professionals in your family? yes no What is his/her family relationship to you? Parent Sibling Aunt/Uncle Grandparent Other His/her occupation: D.O. Physician Assistant Physical therapist M.D. Nurse Mental-health counseling Dentist Medical technician Other Specialization: What is his/her family relationship to you? Parent Sibling Aunt/Uncle Grandparent Other His/her occupation: D.O. Physician Assistant Physical therapist M.D. Nurse Mental-health counseling Dentist Medical technician Other Specialization: What is his/her family relationship to you? Parent Sibling Aunt/Uncle Grandparent Other His/her occupation: D.O. Physician Assistant Physical therapist M.D. Nurse Mental-health counseling Dentist Medical technician Other Specialization: 2

3 Please describe your professional experiences. Job title: Years employed? Field of work: Health-care related Research related Social-services related Business related Military Legal/Law enforcement Other Job title: Years employed? Field of work: Health-care related Research related Social-services related Business related Military Legal/Law enforcement Other Job title: Years employed? Field of work: Health-care related Research related Social-services related Business related Military Legal/Law enforcement Other Please describe significant volunteer experiences. Organization: Years involved? Field of volunteering: Health-care related Community building Social-services related Arts related Other Organization: Years involved? Field of volunteering: Health-care related Community building Social-services related Arts related Other Organization: Years involved? Field of volunteering: Health-care related Community building Social-services related Arts related Other How do you plan to finance your physician assistant education? (Check all that apply) Loans Personal/family funds Military scholarship Other: Please specify 3

4 Military experience: Branch of service: If, yes, was your discharge honorable? 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) AOA AACOM Professional Organization Recruitment Mailing Internet Other Please list any relatives who have attended Lincoln Memorial University. Name Relationship Class Name Relationship Class Name Relationship Class Name Relationship Class 4

5 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. 5

6 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