AISM APPLICATION

305MD

Application for Admissions

Step1

Step2

Section 1

Title (Please select one)

Mr.

Mrs.

Ms.

Dr.

Last Name

First Name

Middle Name

Date of Birth

Place of Birth: City, State, Country

Country of Citizenship

Permanent Resident Status

Social Security # / Canadian SIN #

Permanent Address Line 1

Permanent Address Line 2

Permanent City

Permanent State

Permanent Zip Code

Permanent Country

Home Phone

Work or Day Phone

Fax

Cell Phone

Section 2

What most influenced your application to QUCOM?

Are you currently in the military?

Are you ex-military?

If you are ex-military, which division where you in? Note: Please attach a copy of your military honorable discharge.

How do you plan to finance your medical education?

Indicate (circle) the semester you are applying for:

Please enter the date and scores of your MCAT

List all colleges, universities, and graduate schools you have attended in chronological order

High school graduation date:

Late college/university attended

Beginning attendance date of most recently attended college/university

Ending attendance date of last college/university

What degree have you earned at this institution?

Have you graduated from this institution?

Completion date or expected completion date

Second College Information

College/university attended

Beginning attendance date of college/university

Ending attendance date of college/university

What degree have you earned at this institution?

What was your major?

When did you graduate from this institution?

Third College Information

College/university attended

Beginning attendance date of college/university

Ending attendance date of college/university

What degree have you earned at this institution

What was your major?

When did you graduate from this institution?

Applicants who have completed their undergraduate studies in countries having an educational system different from that of the United States will be evaluated on their merits but will be expected to have completed a pre-medical curriculum including the pre-requisites comparable to that described on page 4. All required documents, if originally in a foreign language, must be accompanied by a notarized English translation. All transcripts documenting post-secondary course work completed in institutions outside the United States must also be evaluated by an approved international credential evaluation service.

Section 3 The admissions committee requires a chronological listing of the applicant’s employment history since graduation from high school. Please include position held and beginning/end dates. Also include the same information for volunteer work.

Section 4 If you answer “Yes” to any of the following questions, submit a full statement of relevant facts for all incidents along with your application. You may be required to furnish copies of official documents explaining the final disposition of the proceedings.

1. Have you ever been enrolled in or attended any graduate school of any kind, including osteopathic, chiropractic, allopathic or other medical school or healthcare program, or any medical school preparatory program?

2. Have you ever been suspended, expelled, disciplined, disqualified, terminated, placed on probation or otherwise subjected to any sanction or other adverse action by an employer, school, academic program, college or university (whether undergraduate or graduate), osteopathic, chiropractic, allopathic or other medical school or medical preparatory program for:

Poor academic performance

Inappropriate conduct

Substance abuse, whether legal or illegal substances, or use of illegal substances

The Admissions Committee requires a brief personal statement concerning your medical career expectations. On one letter-sized typed page, please summarize, in concise terms, your goals in pursuing a medical career, the personal attributes that qualify you to become a physician, and your assessment of your capacity to meet the technical standards of the university both under the pressures of life on a Caribbean island and in clinical settings which may provide cultural and logistical features differing from those to which you are accustomed. Briefly describe the skills and values you believe a physician should possess to practice medicine. Summarize how your experiences to date demonstrate your acquisition and possession of those skills and values. Please limit your personal statement to 750 words.

Date submitted

Section 1

Section 2

List all colleges, universities, and graduate schools you have attended in chronological order

Second College Information

Third College Information

Section 3

The admissions committee requires a chronological listing of the applicant’s employment history since graduation from high school. Please include position held and beginning/end dates. Also include the same information for volunteer work.

Section 4

If you answer “Yes” to any of the following questions, submit a full statement of relevant facts for all incidents along with your application. You may be required to furnish copies of official documents explaining the final disposition of the proceedings.

ADMINISTRATOR OFFICE