North American-Trained PharmD (NTPD) Program APPLICATION FOR ADMISSION

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1 North American-Trained PharmD (NTPD) Program APPLICATION FOR ADMISSION University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Building Distance Degrees and Programs E. Montview Boulevard, Room V Aurora, CO Mail Stop C238-V20 Phone: Please type all information in the form below and submit the application electronically utilizing the Adobe Acrobat signature process. If signed electronically, your application will be sent directly to the DDP Office. If you choose to provide a physical signature, please submit the completed application with your signature to ipharmd@ucdenver.edu. Spring (Deadline: October 15) Fall (Deadline: May 15) Check the appropriate box for your anticipated semester of entry. If date falls on a weekend or holiday, the deadline is the following business day. The application fee is $ Legal Last First Middle Former/Maiden Social Security Number (US) or Social Insurance Number (Canada) - - Permanent Address Number and Street or P.O. Box City State/Province Zip Code Country County Home Phone ( ) - Colorado residents only Area code Telephone Work/Cell Phone ( ) - Area code Telephone Mailing Address (If different from permanent address) Number and Street or P.O. Box City State/Province Zip Code Country How did you hear about the NTPD Program? The following information is voluntary and is used for statistical purposes only. Age and Birth Date: / / Gender: Male Female Marital Status: Married Single Age Mo Day Year Birthplace Number of Dependents City State or Country Select one category that most accurately reflects your ethnic background American Indian or Alaskan Native Tribal Affiliation Enrollment Number Asian American Hawaiian Native or Polynesian White, not of Hispanic Origin Black or African American, not of Hispanic Origin Hispanic, Chicano, Mexican American, Latino I do not wish to provide this information Choose one or more of the ethnic terms in the list below that further or better describes your ethnic background. African American Caribbean Islander East Indian Hawaiian Native Latino Puerto Rican American Indian Caucasian Eskimo Hispanic Mexican Samoan Asian Indian Chicano Filipino Japanese Micronesian Thai Black Chinese Guamanian Korean Pakistani White Cambodian Cuban Haitian Laotian Polynesian Vietnamese Other

2 ADDITIONAL INFORMATION Pharmacy Licensure List state(s)/province(s) in which you hold a license to practice pharmacy. State/Province License Number License Status Has your license to practice pharmacy ever been suspended or revoked? Yes No If yes, you must include a separate explanation with this application. Criminal Record Have you ever been convicted of a felony or are you under the terms of a deferred judgement? Yes No If yes, you must include a separate explanation with this application. Citizenship U.S. Citizen (If you are a U.S. citizen born outside of the United States you must provide a copy of your U.S. passport or Certificate of Naturalization.) Permanent Resident (Immigrant) Alien Registration Number Date of Issue Non Immigrant on Temporary Status / Country of Citizenship Passport Number Admission Level New Application Reapplication Previously applied to the North American-Trained PharmD Program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences but did not enroll in courses Original Application Year Readmit Previously enrolled in the North American-Trained PharmD Program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences but chose to withdraw or were dismissed from program Last Date of Attendance CU Student Number - - Reinstatement Previously enrolled in the North American-Trained PharmD Program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences but have not registered for a course for 3 or more semesters Last Date of Attendance CU Student Number - - 2

3 COLLEGE AND UNIVERSITY INFORMATION List the accredited pharmacy school(s) from which you graduated. Official transcripts from each institution must be received by the application deadline. Please request college transcripts 2-4 weeks prior to the application deadline. of Institution City and State/Province Dates of Attendance (Mo/Year) Degree /Date Earned Language of Instruction Type of System* Hours Completed *Type of system: Semester (S), Quarter (Q), Trimester (T), Other (O). TRANSFER CREDIT FOR PREVIOUS COURSEWORK List the coursework you wish to transfer from the ACPE accredited doctor of pharmacy program mentioned underneath the college and university information section in this application. There is a transfer evaluation fee of $250 per course listed below, up to four courses (max of $1,000). The student will provide a transfer evaluation fee of $50 per course if wishing to transfer more than four courses. The North American-Trained PharmD Program will award no more than twelve (12) transferable credit hours per student. All transfer evaluation fees are non-refundable, even if the coursework is deemed non-transferable. Completed Course ACPE Accredited Institution Course Completion Date Grade Received* Credit Hours (indicate semester or quarters) Equivalent NTPD Program course Total Number of Courses for Transfer Evaluation: *Please note that official transcripts must be provided for transfer credit to be awarded. PROFESSIONAL PHARMACY EXPERIENCE Total Fee for Transfer Evaluation: Attach a copy of your current resume or curriculum vitae including pharmacy work/practice since graduating with a Bachelor of Science pharmacy degree (or equivalent). Are you an adjoint faculty member for the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences? Yes No If yes, what is your faculty title? Have you served as a preceptor for the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences? Yes No If yes, list dates: List any honors or awards received while in pharmacy school or since graduation from pharmacy school (including honorary societies). 3

4 List professional presentations and the group to which you presented, and/or the titles and citations for any posters, journal articles, publications, inventions or creative work. List memberships, offices held and/or committee participation in professional organizations. Membership, Office or Committee Society Dates LETTERS OF RECOMMENDATION Please provide the names of three individuals (not related to you) who know you well, have agreed to submit recommendations and are in a position to objectively judge your professional, academic and/or personal qualities. Recommendations must be provided by professional contacts, such as employers, supervisors, former faculty, preceptors or professional colleagues. References from clergy, family members, friends or politicians will not be accepted. For purposes of consistency, you must use the standard University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences North American-Trained PharmD Program recommendation form. Letters submitted in lieu of the recommendation form will not be accepted. Recommendation #1 Recommendation #2 Recommendation #3 PROFESSIONAL GOALS Attach a one-page (12 point font, double-spaced on 8 ½ x 11, unlined white paper) personal statement describing your interest in this North American-Trained PharmD Program; your understanding of the clinical pharmacy profession and commitment to patient care; and how a PharmD degree will help you reach your professional goals. SIGNATURE I hereby certify, to the best of my knowledge, that the information furnished on this application is true and complete without omission or misrepresentation of facts, and I attest that my statement of professional goals is a document of my own authorship. Furthermore, if any changes occur in the information furnished on this application during the application process or while I am a student at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, I understand that I am required to report the changes to the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs Office within one month. I understand that if I do not adhere to these standards, it is sufficient cause for rejection or dismissal. Signature of applicant 4 Thank you for completing the admissions form. The Distance Degrees and Programs Office will contact applicants to schedule an appointment to complete the interview, which will be conducted via telephone. Date

5 CHECKLIST FOR APPLICATION To streamline the application process, applicants are encouraged to submit the application and recommendation forms online. All other documents, including the application fee, should be assembled in an application packet and sent to the Distance Degrees and Programs Office in a single mailing. All applicants need to submit the following items by the application deadline: Application Fee the $200 (US) non-refundable application fee in the form of a check or money order made payable to the University of Colorado. Make sure the applicant's name and student or social security number appears on the front of the check or money order. All fees should be made payable in US dollars. Pharmacy License notarized copy of your current pharmacy license(s). Professional History résumé or curriculum vitae including pharmacy work/practice since graduating with a pharmacy degree. Personal Statement statement of professional goals and interest in program. Phone ID copy of driver s license, state-issued ID, passport, or 2x2 passport photo. Recommendations three recommendations provided on the standard University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs recommendation form. Completed forms should be ed directly to the Distance Degrees and Programs office at ipharmd@ucdenver.edu. Transcripts request official transcripts from the school of pharmacy from which you graduated and from any degree program(s) in which you have been enrolled since obtaining your degree in pharmacy. Transcripts for education completed outside of the United States or Canada (except Quebec) must be evaluated and translated by an approved agency and sent directly to the Distance Degrees and Programs (DDP) Office. Transfer Credit Evaluation if applicable, the non-refundable transfer evaluation fee and the following information per course you wish to transfer: course syllabus, course content information, general program information of originating school, academic standards for the originating program and letter of intent TOEFL Exam Visit to find more information about the exam and to sign up for the exam. Please use code number 8776 to indicate the University of Colorado Skaggs School of Pharmacy ipharmcu as the score recipient. After the application deadline, the DDP office will contact candidates to complete: Interview the DDP office will contact selected applicants with directions to schedule and complete an admission interview via teleconference. An offer to interview may not be extended to all applicants. The Distance Degrees and Programs Office will send an acknowledgement and status report to each applicant within six weeks of receiving their application. Applicants will be notified of any missing elements in their application packet and will be given the opportunity to correct deficiencies that are beyond their control. Please keep the Distance Degrees and Programs Office informed of any address, phone, or changes so we may contact you if the need arises ( ipharmd@ucdenver.edu or phone ). Thank you for your application. 5

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