Specialty Program Modification Requirements For US Citizen

Transcription

1 Specialty Program Form (MD/MPH, DVM/MPH, CSPH Residency Program Students) This form is intended for the following individuals: (1) Students who have already been accepted to the joint degree DVM/MPH program; (2) Students who are applying to the joint degree MD/MPH program; (3) Students who are applying to the MPH program who have already been accepted to a CSPH residency program. Individuals specified above should submit the completed form to [email protected] or mail to the address specified at the end of this form with their $50 (domestic)/$75 (international) processing fee. Additional program requirements may apply. Please check program requirements online at Individuals applying to the MPH/MPA, MPH/MURP, MPH, DrPH, or Certificate programs should not use this form and should instead follow the application guidelines posted online at Individuals currently enrolled in a graduate degree-seeking program in a US accredited school of public health who wish to transfer to the Colorado School of Public Health MPH program should contact our Office of Academic and Student Affairs directly at or at [email protected]. Please answer all questions below (please type) Program Information: 1. Please select the appropriate program below: Joint Degree MPH/MD Program Joint Degree MPH/DVM Program MPH Program (Already accepted into a CSPH Residency Program) 2. Please select the year in which you are planning to start please note that we only accept applications for a summer/fall start date: Summer Fall (please enter year) (please enter year) 3. Please rank order your first AND second choice concentrations (please note that the campus location for each concentration appears in parentheses): Animals, People, & the Environment (CSU)

2 Applied Biostatistics (CU Anschutz Medical Campus) Community & Behavioral Health (CU Anschutz Medical Campus) Community Health Education (UNC) Environmental and Occupational Health (CSU) Environmental and Occupational Health (CU Anschutz Medical Campus) Epidemiology (CSU) Epidemiology (CU Anschutz Medical Campus) Global Health and Health Disparities (CSU) Health Communication (CSU) Health Services Research (CU Anschutz Medical Campus) Health Systems, Management & Policy (CU Anschutz Medical Campus) Maternal and Child Health (CU Anschutz Medical Campus) Physical Activity & Healthy Lifestyles (CSU) Public Health Nutrition (CSU) Personal Information 1. Prefix (Mr, Mrs, Ms, etc): 2. First Name: 3. Middle Name: 4. Last Name: 5. Suffix (Jr, Sr, etc) 6. Preferred First Name: 7. Former Last Name: 8. Former Last Name 2: 9. Home Address Line 1:

3 10. Home Address Line 2: 11. Home City: 12. Home State: 13. Home Postal Code: 14. Home Country: Please include your mailing address if different from your home address above 15. Mailing Address Line 1: 16. Mailing Address Line 2: 17. Mailing City: 18. Mailing State: 19. Mailing Postal Code: 20. Mailing Country: 21. Home Phone: 22. Other Phone (please specify which type: cell, work): 23. Address: 24. Date of Birth (XX/XX/XXXX): 25. Gender: 26. Social Security Number (required for those who will be applying for financial aid): 27. Student ID/Empl ID (if previously attended CU): 28. *Optional* Please select one or more racial categories to describe yourself please list all that apply (American Indian or Alaska Native, Asian, Black or African-American, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, White):

4 29. *Optional* Are you Hispanic, Chicano, Mexican, Latino, Cuban, Puerto Rican, South or Central American, or Spanish Origin (Yes/No)? Citizenship If you are a US Citizen or permanent resident, you are a domestic applicant. If you are on any type of US Visa, you are an international applicant. An official TOEFL is required for all international applicants and may be waived for those whose native language is English or who have completed a Baccalaureate or graduate-level degree program at a US institution. 1. Please Specify Your Country of Citizenship: If you are not a US-citizen, please also answer the questions below: 2. Please specify Visa type: 3. Are you a Non US Citizen on Permanent Status (Yes/No): 4. Alien Registration Number (if answered yes to question above): Please note that applicants on certain Visas will be required to submit a financial statement upon admission before an I-20 can be issued. Academic History Please indicate your academic history below, including all institutions that you have attended. Undergraduate (please include additional institutions if necessary) 1. Name of Institution: 2. Name of Institution: 3. Name of Institution:

5 Graduate, if applicable 1. Name of Institution: 2. Name of Institution: 3. Name of Institution: Doctorate, if applicable 1. Name of Institution: 2. Name of Institution: Test Results Please enter your self-reported test results below. (Please note: MPH/DVM student scores will be verified directly with CSU. MPH/MD applicants who took the MCAT will need to forward their official scores to the Colorado School of Public Health.) GRE or Equivalent 1. Date of GRE or Equivalent Exam: 2. Please Specify Type of Exam (GRE, MCAT, DAT, PCAT, LSAT, GMAT): 3. Please Indicate Self-Reported GRE or Equivalent Scores Below (raw score and percentiles):

6 TOEFL (if applicable) 1. Date of TOEFL Exam: 2. Please Indicate Self-Reported TOEFL Scores Below: General Test Score Information: International students/non-us Permanent Residents whose native language is not English or who have not earned a degree in the United States are required to submit an official TOEFL score. Exemptions may be made for applicants whose native language is English or for those who have completed a degree at a US institution. TOEFL scores must have been earned within two years preceding the desired term of entry. Minimum score requirements: 550-paper; 213-computer; 80-internet. Official TOEFL scores should be sent to Code GRE or equivalent test scores cannot be older than 5 years at the time of the application deadline. Acceptable substitutes for the GRE include the DAT, GMAT, LSAT, MCAT or PCAT. Submission of GRE test scores is waived only for students who have successfully completed a CSPH Certificate program with a 3.00 or higher or who have completed a graduate level degree from an accredited US or Canadian institution. Official GRE scores should be sent directly to ETS ID (Please note that MPH/DVM scores will be verified directly with CSU) Residency All those applying for in-state residency at the University of Colorado Denver are required to submit a tuition classification form or you will be classified as a non-resident and pay tuition at the higher out of state rate. You may access this form by downloading it from the Registrar s website at Upon admission to the program, you will be required to complete and mail this form back to the Colorado School of Public Health prior to program matriculation. In-state tuition eligibility requires one year of Colorado domicile (legal residence). Exceptions to the one year requirement are provided for: honorably-discharged members of the U.S. armed forces moving permanently to Colorado; active-duty military; Colorado National Guard members; children of faculty members at state-supported colleges; U.S. citizens who attended 3 years of high school in Colorado immediately prior to enrollment; and employees of companies moving to Colorado with State economic incentives. Information about the Colorado resident/nonresident regulations, including details of these

7 exceptions, is available online at Western Regional Graduate Program (WRGP) Residents of Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming are eligible to enroll in the Colorado School of Public Health at resident tuition rates through the WRGP. Proof of residency will be required upon admission. 1. Are you applying for WRGP? 2. If yes, please indicate the WRGP-eligible state that you are a resident of: Supplemental Information 1. Under the Family Educational Rights and Privacy Act of 1974, students who are admitted and who matriculate into the program to which they apply have the right to access their education record, including letters of recommendation. However, students may waive their right to see their letters of recommendation, in which case the letters will be held in confidence. Do you wish to waive your right to examine the letters of recommendation submitted on behalf of your application (Yes/No)? 2. Are you currently enrolled in a Colorado School of Public Health Certificate Program or have you recently applied? If yes, please indicate which semester and year you applied or were accepted. 3. Please list any courses currently in progress, including the course title and institution. 4. Please list any other graduate programs to which you are applying. 5. How did you hear about our program (on-campus info session, college/career fair, professional conference, website/internet search, other)? Sensitive Data 1. Have you ever been placed on probation, suspended, expelled, or been subject to official disciplinary action from any post-secondary institution for any academic misconduct? If you answer yes, please explain in the space provided below or in a separate document.

8 2. Do you have a pending criminal charge OR have you ever been convicted of a crime, made a plea of guilty, accepted a deferred judgment, been adjudicated, or been required to register as a sex offender? (Misdemeanor traffic offenses are exempt). If yes, please explain the space provided below or in a separate document. Additional Application Requirements Additional program requirements (letters of recommendation, CV, essays) may apply. Please check your specific program requirements online at x. The completed specialty program form should be ed directly to [email protected] or mailed with your processing fee ($50 domestic, $75 international) to the following address: Colorado School of Public Health Attn: Jennifer Pacheco E. 17 th Place, Campus Box B-119 Building 500, 3 rd Floor, Ste C3000 Aurora, CO For questions, please contact the Colorado School of Public Health at or at [email protected]