Saint Christopher IMD College of Medicine

Transcription

1 Saint Christopher IMD College of Medicine Application for Admission Please adhere a full- face passport style photograph This application is for the Four Year M.D Program or the Six Year M.D Program. Please type or print in black ink. Four-Year M.D Program / Six-Year M.D Program Entering class: January 20 August 20 This application is for a: Four-year MD Program / / Six-year MD Program / / New Student / / Transfer Student / / level? Have you applied to St. Christopher IMD College of Medicine before? No / / Yes/ / I. PERSONAL PROFILE Social Security Number/Social Insurance Number: Last Name: First Name: Middle Name: Date of Birth: Gender: Male/ / (mm/dd/yyyy) Female / / Country of Birth: Country of Citizenship: If you are not a U.S Citizen, please fill out this section Are you a permanent résident Yes / / No / / If yes, what is your : Green card holder? Alien Registration Number? If No what is your country of citizenship and résidence What is your passport number? Date of Expiry Current Mailing Address: City/Town: State/Providence: Zip Code/Postal Code: Phone: Country: Fax: 1

2 Permanent Mailing Address (if different from above): City/Town: State/Providence: Zip Code/Postal Code: Phone: Country: Fax: II. FAMILY PROFILE Mother s Full Name: Father s Full Name: Living / / Deceased / / Living / / Deceased / / Address: Phone: Occupation: Age: Academic Degrees: Address: Phone: Occupation: Age: Academic Degrees: III. ACADEMIC PROFILE High School/Secondary School 1: Address: Diploma/Major: Date received: High School/Secondary School 2: Address: Diploma/Major: Date received: Colleges/Universities: Institution I: Undergraduate Graduate Credits Earned: Sem Hrs Qtr Hrs Major: Dates Attended: From: / / To: / / Degree: Did you complete this degree? Yes No, When do you expect to finish? 2

3 Institution 2 Undergraduate Graduate Credits Earned: Sem Hrs Qtr Hrs Major: Dates Attended: From: / / To: / / Degree: Did you complete this degree? Yes No, When do you expect to finish? Grade Point Averages: (Calculated on a 4.0 scale) High School/Secondary School G.P.A. High School /Secondary School G.P.A. Undergraduate Science G.P.A. Cumulative Undergraduate G.P.A. Undergraduate Non- science G.P.A. Overall G.P.A. IV. STANDARDIZED EXAMINATIONS A. Scholastic Aptitude Test (SAT) Test Date Verbal Score Mathematics Score B. American College Testing (ACT) Test Date English Math Reading Science Composite Score C. Medical College Admission Test (MCAT) Test Date Verbal Reasoning Physical Sciences Biological Sciences Writing Section D. Other Educational Systems If you have taken exams like the GCSE, A-levels, HND, or IB, please indicate below. Examination Date Subject Score Institution 3

4 E. Test of English as Foreign Language (TOEFL)/International English Language Testing System (IELTS) Please complete this section if English is not your native language. If you have taken the examination, please have your scores sent directly from the testing agency. Test Date: Score: V. LIFE EXPERIENCES A. Employment Experience Please submit a résumé or curriculum vitae with your application. References should be included. Did you work while in school? No: Yes Hours/Week? B. Volunteer Experience Have you volunteered for a healthcare organization? No: Yes Hours/Week? Please provide details about your volunteer work: Dates Organization Role What healthcare experience do you have? Please list your extracurricular activities: Please list any honors, awards, or special distinctions. 4

5 VI. ESSAYS Please complete all the following essays and submit them with your application. Include your name and Social Security number on each page. 1. Please discuss your medical career expectations as a future physician. (approx. 500 words) 2. What significant accomplishments or life experiences make you unique? (approx. 250 words) 3. Why would you be an asset to St. Christopher IMD College of Medicine? (approx. 250 words) VII. PERSONAL HISTORY Please complete all the questions in full. If you answer yes to any of the following questions, please submit an explanation on a separate sheet of paper. Print or type in black ink. 1. Have you ever been dismissed or disqualified or suspend from any academic institution? 2. Have you ever been disciplined by an academic institution for any violation? 3. Have you ever been charged with a violation resulting in probation or community service or incarceration? 4. Have you ever been convicted or a felony or a misdemeanor except for parking violations? 5. Have you ever been treated for any mental or emotional illness or learning disorder? 6. Have you ever taken any prescription drugs for any mental or emotional illness or learning disorder? 7. Have you ever had a license denied, suspended, or revoked by any regulatory committee? 8. Have you ever been disciplined before by any academic or professional committee or denied admission by any professional organization? 9. Do you have any physical disabilities or medical conditions that may need special attention? 10. Have you ever attended a medical school before? You must read and sign the following section in order to complete your application. I understand that S. Christopher IMD College of Medicine reserves the right to accept or deny any applicant. St. Christopher IMD College of Medicine grants admission to students regardless of color, race, nationality, religion, gender, disability or marital status. I hereby state that all the information in this application is true and that I am responsible for paying all my dues on time. I will conform to all the terms and conditions pertinent to being a student at St. Christopher IMD College of Medicine. I also understand that the direction of the College is subject to change without prior notice. Applicants providing St. Christopher IMD College of Medicine with incorrect or misleading information will be denied admission, dismissed, or have their degree nullified at any future time. Signature: Date: Print: 5