Please staple all five (5) pages together before submitting. University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences North American-Trained PharmD Program APPLICATION FOR ADMISSION Mailing Address: Distance Degrees and Programs Office 12850 E. Montview Blvd., Room V20-1116 Aurora, CO 80045 Mail Stop (C238-V20) (303) 724-3582 Please print out the application form and type or use black ink. Do not fill out online. 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 $50.00. Spring (Deadline October 15) Fall (Deadline May 15) Full Legal Last First Middle Former/Maiden Social Security Number - - - - Or Social Assurance Number (Canadian Applicants Only) CU Student Number, If Different Permanent Address Number and Street or P.O. Box - City State Zip code Country County Home Telephone ( ) Colorado residents only Area code Telephone Mailing Address (If Different From Permanent Address) Number and Street or P.O. Box - City State Zip code Country Work Telephone ( ) E-mail: Area code Telephone Ext. 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 the one category that most accurately reflects your ethnic background) American Indian or Alaskan Native Tribal Affiliation Enrollment Number Hawaiian Native or Polynesian Hispanic, Chicano, Mexican American, Latino Asian American Black or African American, not of Hispanic Origin White, not of Hispanic Origin 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. American Indian Chinese Hispanic Polynesian Asian Indian Cuban Japanese Puerto Rican African American East Indian Korean Samoan Black Eskimo Laotian Thai Cambodian Filipino Latino Vietnamese Caribbean Islander Guamanian Mexican White Caucasian Hawaiian Native Micronesian Other Chicano Haitian Pakistani Other
ADDITIONAL INFORMATION Pharmacy Licensure List state(s) in which you hold a license to practice pharmacy. State 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 English Proficiency In which city, state, and country did you attend high school? Admission Level New Application Reapplication (Have previously applied to the North American-Trained PharmD Program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences) Year Readmit (Have previously been enrolled in the North American-Trained PharmD Program at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences) Year 2
COLLEGE AND UNIVERSITY INFORMATION List the accredited pharmacy school(s) from which you graduated and any degree program(s) in which you have been enrolled since obtaining your BS in pharmacy. 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 State Zip From To Degrees and Dates Earned 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 nontraditional 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. of Course Completed of the ACPE Accredited Institution Date Course Completed Grade Received* Semester Credit Hours of North American- Trained PharmD Program Course to Receive Transfer Credit Transfer Evaluation Fee *Please note that official transcripts must be provided for transfer credit to be awarded. Total Amount for Transfer Evaluation Fee: PROFESSIONAL PHARMACY EXPERIENCE 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? 3
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). 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. 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 and how a PharmD degree will help you reach your professional goals. 4
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. 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 North American-Trained PharmD Program within one month. I understand that if I do not adhere to these standards, it is sufficient cause for rejection or dismissal. Please Note: The application must bear an original signature, not digital or printed. Signature of applicant Date 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. CHECK LIST FOR APPLICATION To streamline the application process, applicants are encouraged to assemble the following items in an application packet and send it to the Distance Degrees and Programs office in a single mailing. Request official transcripts from the accredited school of pharmacy from which you graduated and from any degree program(s) in which you have been enrolled since obtaining your BS in pharmacy. The official transcripts must be sent directly to the Distance Degrees and Programs office. Personal statement and professional goals. The $50 non-refundable application fee in the form of a check or money order made payable to the University of Colorado Anschutz Medical Campus. Make sure the applicant's name and student or social security number appears on the front of the check or money order. Canadian applicants should use money orders made payable in US dollars. Three recommendations provided on the standard University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences North American-Trained PharmD Program recommendation form (in sealed envelopes bearing the recommender s signature across the seal). Notarized copy of your current pharmacy license(s). Resume or curriculum vitae including pharmacy work/practice since graduating with a bachelor of science pharmacy degree (or equivalent). 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 If applicable, completion of the TOEFL exam. Visit www.ets.org/toefl 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 as the score recipient. If applicable, a notarized copy of the Foreign Pharmacy Graduate Equivalency exam score and certificate. Interview - The Distance Degrees and Programs office will contact applicants to schedule an appointment to complete the interview, which will be conducted via telephone. 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 email changes so we may contact you if the need arises (email: NTPD@ucdenver.edu or phone 303-724- 3582). Thank you for your application. 5