DOCTOR OF PHARMACY (PharmD) PROGRAM 2017 SUPPLEMENTAL APPLICATION

Transcription

1 DOCTOR OF PHARMACY (PharmD) PROGRAM 2017 SUPPLEMENTAL APPLICATION Please application and online payment receipt to: There is only one (1) supplemental application and one (1) fee to apply to both the Henderson, Nevada and South Jordan, Utah campuses. Interviews are held at both the Nevada Campus 11 Sunset Way, Henderson, NV and Utah Campus South River Front Parkway, South Jordan, UT To be eligible to apply to the College, you must also apply through PharmCAS at PharmCAS does require an additional fee paid directly to PharmCAS. The PDF format allows you to click on each field, type in the requested information and save the form. Read all instructions and proofread your application before submitting it to the College. Any omissions will significantly delay the processing of your application and may result in denial of admission. You should keep a copy of the completed application for your records. your completed application and a copy of your online payment receipt to: admissionspacket@roseman.edu APPLICATION DEADLINE: All applications must be received by February 1, Applicants applying through the Early Decision Program must submit their application by September 6, APPLICATION RECEIPT NOTIFICATION: You will be notified of receipt of your supplemental application via . 1

2 PERSONAL / BIOGRAPHICAL INFORMATION 2017 Supplemental Application FULL LEGAL NAME Last First Middle All names MUST match the name and order on your birth certificate, U.S. Passport, marriage license, court order, naturalization certificate, permanent resident card or official government visa. (A driver s license or social security card is NOT considered evidence of your legal name.) Other Name: Last: First: Middle: If you are using or have used any other name on academic records (i.e. maiden name or name different than it appears on your birth certificate, passport or government document not including nicknames) provide that name here. If you have not used any other name, leave blank. HAVE YOU APPLIED BEFORE? NO YES (Academic Year) U.S. SOCIAL SECURITY NUMBER (last 4 digits) DATE of BIRTH (MM/DD/YYYY) / / (Required by January 1, 2017) GENDER: Male Female Campus Preference: First choice Second choice MAILING ADDRESS CITY STATE ZIP CODE HOME PHONE CELL PHONE WORK PHONE (do not list cell number on this line) ADDRESS (do not list cell number) (You must contact the Admissions Office in writing ( accepted) with any address or telephone number changes) CITIZENSHIP U.S. Citizen: Birth Naturalization Non-U.S. Citizen: (You must have F-1 Visa Status and obtain a U.S. Social Security Number to enroll at ROSEMAN UNIVERSITY) Permanent Resident I-20 issued by (Current Institution): Government Visa / Asylum / Other please specify: ETHNICITY (please check one, response is optional) American Indian or Alaska Native Asian Black or African-American Hispanics of any race Native Hawaiian or Other Pacific Islander White, Non-Hispanic Two or more races Race & Ethnicity unknown 1 2

3 You must complete the PCAT on or before January 5, 2017 (Early Decision Program applicants must complete their PCAT on or before July 22, 2016): Yes, I completed the PCAT on. No, I have not completed the PCAT. The date that I will complete the PCAT is. No, the PCAT requirement is waived. I have/will have a bachelor s degree or higher verified by PharmCAS. OPTIONAL - ACADEMIC FORGIVENESS POLICY You may request that Roseman University College of Pharmacy Admissions Office ONLY use grades from the last five years to calculate your overall and science/math prerequisite grade point averages. If you want to request this option, please indicate check the box below: Yes, I request Academic Forgiveness (AF) You must complete 5 out of 8 math and science prerequisites by December 31, 2016 (or by September 6, 2016 for Early Decision applicants) and be able to finish the remaining prerequisites before classes begin in August. By making this request you must have completed or will have completed all TEN required prerequisites between January 1, 2012 and August 15, BACKGROUND INFORMATION (Initials) I acknowledge that enrolled students are required to successfully complete a criminal background check and drug screening. I understand that if I don t pass the drug screening or my criminal background check shows a conviction for a misdemeanor or felony, or reveals any other adverse information, I may not be able to participate in experiential rotations. If I am unable to complete the experiential component of my education, I understand that Roseman University will be unable to award me a degree. Has any health professions licensing or regulatory board or authority ever imposed conditions upon or otherwise restricted your ability to practice one of the health professions? NO YES* If yes, please explain: * If you answered YES to the questions above, you must initial one (1) of the statements below: (Initials) YES, I contacted the Nevada (bop.nv.gov) and/or Utah (dopl.utah.gov) Boards of Pharmacy and they informed me that I am eligible for an intern pharmacist license. (Initials) NO, the Nevada (bop.nv.gov) and/or Utah (dopl.utah.gov) Boards of Pharmacy have NOT informed me that I am eligible for an intern pharmacist license. I understand that I MUST be eligible to obtain a Nevada or Utah State Board of Pharmacy Intern Pharmacist Certificate of Registration before I can enroll in the program. Technical Standards for Admission, Advancement, and Graduation (Initials) YES, I have reviewed the Technical Standards for Admission, Advancement, and Graduation as listed on the Roseman College of Pharmacy website at I understand that I must meet these technical standards in order to be considered for admission into the Pharm.D. program. 3

4 Honors / Awards / Extracurricular / Volunteer Activities / Leadership (List only, if necessary, please add additional pages.) A. Please list any honors, awards, scholarships, extracurricular activities, etc. B. Please list any volunteer activities (i.e. unpaid) you have participated in such as blood drives, Red Cross, hospital or pharmacy work (e.g. shadowing, intern), animal therapy, etc. C. Please list any examples that demonstrate your leadership experience, such as positions held as class officer, committee chair, etc. Pharmacy or other health care employment (paid) experience: Pharmacy: NO YES: Retail Hospital Other Pharmacy Technician: NO YES If yes, please list pharmacy or health care employer s name, address, position held, and dates employed. 3 4

5 ESSAY QUESTIONS Please answer the following questions, but do not exceed the amount of space allotted, using size 10 font only. 1) Why is Roseman University s approach to pharmacy education a good fit/match for you? 2) Why would a student in Roseman University s PharmD program want you to be a member of her/his team? 5

6 ESSAY QUESTIONS CONTINUED 3) How will you be an outstanding representative/role model for Roseman University College of Pharmacy? 4) For applicants re-applying to the PharmD Program ONLY: Please describe how you have improved academically, personally and/or professionally within the last year. **Please tell us how you learned about Roseman University** (please check one or more) Academic Advisor Current/Former Student Employer Event (Open House, on campus recruiting event) Friend/Word of Mouth Internet Search Newspaper/Magazine article Professor/Teacher Social Media Undergraduate/Graduate Fair/Health Professions Fair) Other 5 6

7 ROSEMAN UNIVERSITY OF HEALTH SCIENCES COLLEGE OF PHARMACY 2017 APPLICATION APPLICANT CODE OF CONDUCT POLICY The Assistant Dean for Admissions and Student Affairs reserves the right to adjust an applicant's admissions status, disqualify an applicant from admissions consideration or rescind an offer of admission at Roseman should the applicant violate the PharmCAS Applicant Code of Conduct and/or demonstrate a lack of professionalism during the admissions process. CERTIFICATION This certification must be signed and dated by the applicant to proceed with the application process. By signing this page, I acknowledge that I understand and agree to the application instruction and policies, including the applicant code of conduct. I certify that the information on this application is complete and correct and understand that the submission of false information or omission of information is grounds for rejection of my application, withdrawal of any offer of acceptance, cancellation of enrollment, or appropriate disciplinary actions. I hereby consent to and authorize any educational institution I have attended to release any academic and/or disciplinary information to Roseman University. I agree to notify the proper officials of the institution of any changes in the information provided on this application. I also agree to pay all reasonable collection costs, including attorney fees and other charges necessary for the collection of any amount owed to Roseman University. I am submitting this supplemental application along with the U.S. $60 non-refundable application fee. Applicant Signature Date EMERGENCY CONTACT INFORMATION Name: Phone: If you have any questions, contact: Dr. Helen Park Dawn Marie Benson Assistant Dean for Admissions and Student Affairs Admissions Specialist hpark1@roseman.edu dbenson@roseman.edu Phone: Phone: NON-DISCRIMINATION POLICY The University does not discriminate on the basis of age, race, color, national origin, religion, handicap, marital status, or sexual orientation. 7