International-Trained PharmD (ITPD) Program APPLICATION FOR ADMISSION University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Building Distance Degrees and Programs 12850 E. Montview Boulevard, Room V20-1116 Aurora, CO 80045 Mail Stop C238-V20 Phone: 303-724-3582 ipharmd@ucdenver.edu 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. Summer 2017 (Deadline: January 15, 2017) Summer 2018 (Deadline: January 15, 2018) 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 $200.00. Legal Last /Family /Surname First Middle Preferred /Nickname Other s (Please list other names that may appear on your academic records): National Identification Number (if available) Examples: Social Security Number (US), Social Insurance Number (Canada) Passport Number Country Permanent Address Number and Street or P.O. Box City State/Province Postal Code Country Primary Phone ( ) Secondary Phone ( ) Country code Telephone Country code Telephone E-mail: Mailing Address (If different from permanent address) Number and Street or P.O. Box City State/Province Postal Code Country How did you hear about the ITPD 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
ADDITIONAL INFORMATION Pharmacy Licensure or Certificate List state(s)/province(s)/country(s) in which you hold a license to practice pharmacy. State/Province/Country 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 local equivalent, or are you under the terms of a deferred judgment? 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 COLLEGE AND UNIVERSITY INFORMATION List the pharmacy school(s) from which you graduated and any degree program(s) in which you have been enrolled since obtaining your degree in pharmacy. Official transcripts from each institution must be received by the application deadline. Please request college transcripts 8-12 weeks prior to the application deadline. of Institution City and State/Province and Country 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). 2
PROFESSIONAL PHARMACY EXPERIENCE Attach a copy of your current resume or curriculum vitae including pharmacy work/practice since graduating with a bachelor of pharmacy degree (or equivalent). Have you served as a preceptor for pharmacy students? 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. 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 Distance Degrees and Programs recommendation form. Letters submitted in lieu of the recommendation form will not be accepted. Recommendation #1 Recommendation #2 Recommendation #3 3
PROFESSIONAL SPONSORSHIP Please provide the name of the individual who has agreed to serve as your professional sponsor. A professional sponsor (typically an employer), will attest to their support of your pursuit of the degree program, and your plans for expanding the practice of patientcentered pharmacy care outside the United States. This sponsorship does not require financial sponsorship. If the professional sponsor is also serving as a reference they must submit a letter of recommendation and a professional sponsor letter. Professional Sponsor PERSONAL STATEMENT OF PROFESSIONAL GOALS Attach a personal statement (please submit a typed document (4 pages maximum) using 12 point font, double-spaced, on A4 paper). In your personal statement, please address the following questions: Why are you interested in obtaining a PharmD from the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences? What would you do to advance pharmacy s role in patient-centered care outside of the United States? What is your plan for completing the online curriculum? Specifically, how will you find the time to complete the required coursework? Students in the ITPD Program will be required to come to the United States at the beginning of the program for 4 weeks. At the end of the program, students will return for a minimum of 30 weeks to complete the remaining portion of the didactic curriculum and rotation experiences. The 30 week timeframe is based on completing the didactic curriculum and rotation experiences back-to-back; however, students are not required to complete all rotations in one visit. Considering that: o o What is your plan for completing the clinical rotation experiences in the United States? How do you think this will impact you, your family, your current employer, your finances, etc.? What is your planned timeline for completing all necessary coursework and graduation? 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 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 video teleconference. 4
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 January 15th: 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 or barrister-certified copy of your current pharmacy license(s)/certificates. Documents in a foreign language must be translated by an approved translation service. Professional History resume or curriculum vitae including pharmacy work/practice since graduating with a pharmacy degree (or equivalent). Personal statement and professional goals. 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 emailed directly to the Distance Degrees and Programs office at ipharmd@ucdenver.edu. Professional sponsorship one professional sponsorship provided on the standard University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs professional sponsorship form. Completed forms should be emailed 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. The official transcripts must be evaluated and translated by an approved agency and sent directly to the Distance Degrees and Programs (DDP) Office. 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 ipharmcu as the score recipient. Competency exam or FPGEE complete and pass the competency exams or provide proof of a passing FPGEE score. Scores for exams taken prior to 2003 will not be accepted. If completing the competency exams, applicants should submit the Test Authorization Request Form at least 5 business days prior to testing. Applicants should provide a notarized copy of the FPGEE score. Upon review of all applications, candidates selected to continue the admissions process will need to complete: Oral Proficiency Interview (OPI) the DDP Office will provide selected applicants with directions to complete a 30-minute OPI by telephone as a portion of the evaluation of English proficiency. Written Essay the DDP Office will provide selected applicants with directions to complete a written essay as a portion of the evaluation of English proficiency. 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 email changes so we may contact you if the need arises (email: ipharmd@ucdenver.edu or phone 303-724-3582). Thank you for your application. 5