ذدà،±ل>‏ے €¥?§?$?%?&?'?(?)?*?+?,?-?.?/?0?1?2?3?4?5?6?7?8?9?:?;????@?A?B?C?D?E?F?G?H?I?J?K?L?M?N?O?P?Q?R?S?T?U?V?W?X?Y?Z?[?\?]?^?_?`?a?b?c?d?e?f?g?h?i?j?k?l?m?n?o?p?q?r?s?t?u?v?w?x?y?z?{?|?}?~??€?پ?‚?ƒ?„?…?†?‡?ˆ?‰?ٹ?‹?Œ?چ?ژ?ڈ?گ?‘?ى¥ء%` ّ؟b`bjbj®ُ®ُ =cجںجںf(ےےےےےے¤وووو666d¼ˆˆˆˆtüLہKTjjjja&‡“bJdJdJdJdJdJdJ$ NhqPRˆJ96ê-ه|aê-ê-ˆJووjj{ءJ000ê-”و8j6jbJ0ê-bJ00ق8X6¦:jHگqژِîؤبˆ~.Td9ئ:œ×J0K~:(أPز/"أPP¦:أP6¦: ›*إ"°0u&ôi)پ›››ˆJˆJô/(›››Kê-ê-ê-ê-ہہہن~¤کن}ہہہ¤کڑ®¼ووووووےےےے SCHOOL OF MEDICINE APPLICATION FOR ADMISSION St. Matthew’s University School of Medicine Application Instructions and Checklist This package contains the forms needed to apply to St. Matthew’s University School of Medicine and for financial aid. Application packets that are filled out completely require less handling and will result in timely notification of status. Request for Transcript forms are mailed in window envelopes. Please type or print mailing information clearly. The materials included are: Application for Admission Form (1) Request for Transcript forms (3 per page) Letter of Recommendation forms (make copies for additional letters) The following materials included are to be used if you are applying for financial aid: Financial Aid Verification Worksheet (1) Financial Aid Statement of Intent for Payment of Tuition (1) Loan Disbursement Authorization (1) Scholarship Application (1) A large postage paid envelope is included to return all materials and information to St. Matthew’s University. The completed Application Packet and Financial Aid Information should be returned to St. Matthew’s Admissions Office. Include all of the following. This checklist is provided for your convenience: Application for Admission Form Please complete ALL parts of the form. Do not leave any sections blank. Request for Transcript Forms (academic transcripts) All prior credits or degrees must be verified by an official transcript (or score report) mailed directly to St. Matthew’s University School of Medicine by the issuing institution(s). If additional Request for Transcript Forms are needed, make a copy of the enclosed original. Carefully complete one Request for Transcript Form for EVERY college or university you have attended. Providing complete information on these requests will prevent delays in the admission process. Please be SURE you have signed each form in blue ink. Mail one form to each institution you have attended. Transcripts ineligible for release are the student’s responsibility to remedy. Personal Statement Applicants must submit a personal statement with the application form. This offers an opportunity for the applicant to describe those personal attributes, characteristics, and interests that underlie the decision to study medicine. Participation in research projects, hobbies, and health-related employment or volunteer work may be considered in the deliberations of the admissions committee Letters of Recommendation Confidential appraisals by college advisors, instructors, or others are an important part of the application. Recommendations should be sought from individuals who know the applicant well. (Additional instructions can be found on the Letter of Recommendation Form.) Three Passport Photos - one must be a side (profile) view These photos will be used in your student file as well as for student identification badges, etc. $75. Nonrefundable Application Fee (Check or Money Order) MCAT Scores (requested on all applications received after January 1, 2007) Current Resume Financial Aid Verification Worksheet: This form must be completed in full before any financial aid applications can be considered or forwarded to Key Bank, etc. It is REQUIRED for all financial aid recipients. Financial Aid Statement of Intent for Payment of tuition Loan Disbursement Authorization: This form must be completed in full before any financial aid applications can be considered or forwarded to KeyBank, etc. It is REQUIRED for all financial aid recipients). Application for Scholarship: Complete this application only if you meet stated criteria. Additional information regarding St. Matthew’s University School of Medicine may be obtained by contacting the State Board of Independent Colleges and Universities, Department of Education, Tallahassee, FL 32399 (850) 488-8695 or toll free (888) 224-6684 ST. MATTHEW’S UNIVERSITY SCHOOL OF MEDICINE APPLICATION FOR ADMISSION Please print or type then mail completed application with additional documents and three passport photos to: St. Matthew's University School of Medicine12124 High Tech Avenue, Suite 350Orlando, Florida 32817Phone: 1.800.498.9700 Fax: 1.800.565.7177 Email: HYPERLINK "mailto:admissions@stmatthews.edu"admissions@stmatthews.edu STATUS: ____First Year ____Advance Standing* ____Transfer PROGRAM: ____ MD Program ___MD/MBA Program TERM/YEAR: (please be specific) ،% Fall 07 ،% Spring 08 ،% Summer 08 ،% Fall 08 ،% Spring 09 ،% Summer 09 ،% Fall 09 ،% Spring 10 ،% Summer 10 ،% Fall 10 ،% Spring 11 ،% Summer 11 * Any transfer credits accepted are at the discretion of the University. GENERAL INFORMATION SOCIAL SECURITY NUMBER: ________-_____-_______ DATE OF BIRTH: ______________ MM/DD/YY FULL LEGAL NAME: ______________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL PERMANENT ADDRESS: __________________________________________________________________________________________ STREET ADDRESS OR P. O. BOX ___________________________________________________________________________________________ CITY STATE COUNTRY ZIP HOME PHONE: ______________________ WORK PHONE: _________________ CELL PHONE: ___________________ EMAIL:_________________________ MARITAL STATUS: _____SINGLE _____MARRIED SEX: ___MALE ___FEMALE EMERGENCY CONTACT: __________________________________________RELATIONSHIP:_____________PHONE:______________ EMERGENCY ADDRESS: _____________________________________________________________________ STREET ADDRESS OR P. O. BOX ___________________________________________________________________________________________ CITY STATE COUNTRY ZIP ARE YOU A CITIZEN OF THE UNITED STATES? ________YES_______NO IF NOT A CITIZEN, WHAT IS YOUR VISA STATUS: _____________________________________GENERAL INFORMATION HAVE YOU EVER BEEN CONVICTED OF ANY CRIMES OTHER THAN A MINOR TRAFFIC INFRACTION? ___YES ____NO St. Matthew’s now requires a local criminal activity report. (IF THE ANSWER IS YES PLEASE ATTACH A FULL EXPLANATION ON A SEPARATE PAGE.) HAVE YOU EVER BEEN SUSPENDED, DISMISSED, OR FORCIBLY WITHDRAWN FROM AN INSTITUTION FOR NONACADEMIC REASONS? ____YES ____NO (IF THE ANSWER IS YES, PLEASE ATTACH A FULL EXPLANATION ON SEPARATE PAGE.) ETHNIC BACKGROUND: (REQUIRED FOR STATE AND FEDERAL REPORTING)American Indian or Alaskan Native Arabic Black Chinese Egyptian Filipino Greek Hawaiian Hispanic-Mexican American or Chicano Hispanic-Other (including Cuban) Hispanic- Puertorican- Common Wealth Hispanic- Puertorican- Mainland Israeli Japanese Korean Middle-Eastern Other Asia Other Pacific Islander S.E. Asian but not Vietnamese Syrian Turkish Vietnamese White Other (specify country): _____________________ WHAT IS YOUR FIRST LANGUAGE: _____________________________WHERE DID YOU FIRST LEARN ABOUT ST. MATTHEW’S UNIVERSITY? Advertisement Email Facebook Family Member _________________ Friend _________________ Graduation Fair Health Professions Advisor ________________ Internet Letter Medical Professional Med School Poster Postcard Preview Event Search Engine SMU Applicant SMU Faculty SMU Graduate SMU Student Test Preparation VendorFINANCIAL AID INFORMATION: DO YOU PLAN TO APPLY FOR FINANCIAL AID _____YES _____NO FAMILY COLLEGE HISTORY: HAS ANY MEMBER OF YOUR FAMILY RECEIVED AN M.D. DEGREE? IF SO, WHAT IS THEIR RELATIONSHIP TO YOU? _______________________________________ PAYMENT INFORMATION: A $75.00 application fee must accompany this form. METHOD OF PAYMENT: ___CHECK ___MONEY ORDER ___CREDIT CARD (ONLY VISA OR MATERCARD) IF CREDIT CARD, WHAT TYPE: _____VISA _____MASTERCARD CREDIT CARD NUMBER______________________________________EXPERATION DATE:_______________ (Month/Year) CERTIFICATION STATEMENT The filling out and mailing of this form acknowledges that I understand that withholding information requested in this application or giving false information may make me ineligible for admission to or continuation in St. Matthew’s University. With this in mind, I certify that the above statements and information provided are correct and complete. I give permission to St. Matthew’s University, School of Medicine to charge my Credit Card for application fee purposes only._____(please initial) No person shall be excluded from participation in, denied benefits of, or be subject to discrimination under any program or activity sponsored or conducted by St. Matthew’s University, on any basis prohibited by applicable law, including but not limited to, race, color, national origin, sex, age, or handicap. I will be bringing family (spouse, kids) with me when classes start _______Yes _______No (Note: this is for housing purposes only) I give permission for St. Matthew’s University to use photos of me in materials that enhance the university image. ______________________________________ ____________________________________ SIGNATURE OF APPLICANT DATE Academic Information MCAT SCORE: DATE TAKEN _________ VERBAL________ PHYSICAL SCIENCE________ WRITING_________ BIOLOGICAL SCIENCE________ NUMBER OF COLLEGE HOURS COMPLETED: SEMESTER HOURS _______QUARTER HOURS ________ OVERALL UNDERGRADUATE GPA: ______ OVERALL SCIENCE GPA:_____ OVERALL GRADUATE GPA: _______ ACADEMIC RECORD A official transcript must received from each institution prior to Admissions Committee review University/College Attended*DatesMajorDegree(s) Earned * All foreign transcripts must be evaluated, on a course-by-course basis. FOR STUDENTS WITH MEDICAL SCHOOL TRANSFER WORK Medical School AttendedLocationDates attended LIST ANY SCHOLARSHIPS, AWARDS, DISTINCTION, OR SPECIAL ACADEMIC ACHIEVEMENTS:_____________________________________________________________________________ ___________________________________________________________________________________________ INTERESTS, HOBBIES, NON-ACADEMIC ACTIVITIES: ___________________________________________________________________________________________ EMPLOYMENT HISTORY: (BEGIN WITH YOUR CURRENT OCCUPATION) JOB & TITLEPLACE OF EMPLOYMENTDATESPRE-MED COURSEWORK PLEASE LIST ALL UNDERGRADUATE AND GRADUATE COURSES IN THE SPACE PROVIDE BELOW. AN “OFFICIAL TRANSCRIPT” MUST BE RECEIVED PRIOR TO ADMISSIONS COMMITTEE REVIEW. PLACE AN X TO INDICATE UNDERGRADUATE OR GRADUATE WORK. ATTACH ADDITIONAL SHEETS IF NECESSARY. (YR = Year, GD = Grade, CE = Currently Enrolled, DC = Date of Completion, G = Graduate, U = Undergraduate) BIOLOGY Title YR GDCEDCInstitutionGU CHEMISTRY TitleYR GDCEDCInstitutionGU PHYSICS TitleYR GDCEDCInstitutionGU MATHEMATICS or RELATED COURSES TitleYR GDCEDCInstitutionGU PSYCHOLOGY, SOCIOLOGY or RELATED COURSES TitleYR GDCEDCInstitutionGU Request for Transcript for Admission to St. Matthew’s University School of Medicine ATTENTION REGISTRAR’S OFFICE FROM: Last Name First Name Middle Name Please process this request within two (2) weeks. If you __________________________________________________ encounter any difficulties in processing, please contact NAME ON TRANSCRIPT: (if different from above) St. Matthew’s University Admissions Office at: 800.498.9700. Social Security Number ___________-_______- Please send one (1) Official Academic Transcript to: ID Number, if any: ____________ Date of Birth: Transcript Department ACADEMIC TRANSCRIPT REQUEST ENCLOSED St. Matthew’s University School of Medicine 12124 High Tech Avenue, Suite 350 Orlando, FL 32817 College/University Street Address X Student Signature City State Zip Country Request for Transcript for Admission to St. Matthew’s University School of Medicine ATTENTION REGISTRAR’S OFFICE FROM: Last Name First Name Middle Name Please process this request within two (2) weeks. If you ______________________________________________ encounter any difficulties in processing, please contact NAME ON TRANSCRIPT: (if different from above) St. Matthew’s University Admissions Office at: 800.498.9700. Social Security Number ___________-_______- Please send one (1) Official Academic Transcript to: ID Number, if any: ____________ Date of Birth: Transcript Department ACADEMIC TRANSCRIPT REQUEST ENCLOSED St. Matthew’s University School of Medicine 12124 High Tech Avenue, Suite 350 Orlando, FL 32817 College/University Street Address X Student Signature City State Zip Country Request for Transcript for Admission to St. Matthew’s University School of Medicine ATTENTION REGISTRAR’S OFFICE FROM: Last Name First Name Middle Name Please process this request within two (2) weeks. If you __________________________________________________ encounter any difficulties in processing, please contact NAME ON TRANSCRIPT: (if different from above) St. Matthew’s University Admissions Office at: 800.498.9700. Social Security Number ___________-_______- Please send one (1) Official Academic Transcript to: ID Number, if any: ____________ Date of Birth: Transcript Department ACADEMIC TRANSCRIPT REQUEST ENCLOSED St. Matthew’s University School of Medicine 12124 High Tech Avenue, Suite 350 Orlando, FL 32817 College/University Street Address X Student Signature City State Zip Country St. Matthew’s University School of Medicine Confidential Recommendation ___________________________________________________________________________________ DIRECTIONS FOR APPLICANT: Please fill in your name and ask your reference to complete this confidential recommendation form and either return it directly to St. Matthew’s or to you in a sealed envelope with the signature of the reference across the seal. Applicant’s name: Last First Middle Applicant’s Contact Info: Phone Email Address DIRECTIONS FOR REFERENCE: The individual whose name appears above is applying for admission to St. Matthew’s University School of Medicine. We would appreciate your candid assessment of this individual’s potential for the successful completion of the Doctor of Medicine degree. Your comments about the individual’s initiative, maturity, self-motivation, and intellectual capacities are required in order for St. Matthew’s to determine the applicant’s suitability for the MD program. This form will remain strictly confidential. Thank you for taking the time to complete this reference form. Reference Signature Reference’s Name (printed or typed) _______________________________________________ Position or Title Organization _______________________________________________ Street or PO Box Telephone _______________________________________________ City State Zip Fax or Email INFORMATION: How long have you known the candidate? ________years ________months In what capacity have you known the candidate_____________________________________ Compare the candidate on the scale below with others you have known during your career. Indicate your assessment in the boxes below. Please check only one box per category. OutstandingGoodPoorCannot EvaluateAcademic background for medicineEvidence of academic ability/skillsEvidence of clinical skills/abilityEvidence of scholarly writing abilityEvidence of professionalism/ethicsEvidence of service to others/volunteerism Capacity for independent studyEvidence of organizational skillsEvidence of goal direction/self starting WRITTEN ASSESSMENT: Please provide a candid assessment of this individual’s potential for success in medical school on a separate page or on the back of this page. Include a description of specific activities or accomplishments that show his/her strengths and weaknesses. Give examples of the applicant’s scholarship and professional accomplishments and potential for contributing to scholarship and practice as a Medical Doctor. Note to the Reference: You may return this form directly to the United States office of St. Matthew’s University School of Medicine,12124 High Tech Avenue, Suite 350 Orlando, FL 32817 or to the applicant by sealing it in an envelope and signing your name across the seal. St. Matthew’s University School of Medicine Financial Aid Verification Worksheet This form is being used in lieu of the federal verification worksheet. Its purpose is to verify information needed to certify your application for Financial Aid. This form is required for all Financial Aid recipients. Please complete all sections and sign the form at the bottom. Part I. Student Information Name: (First, MI, Last)___________________________________________________________ SSN___________-_______-__________ DOB (mm/dd/yy)_____________________ Address_______________________________________________________________________ City, ST, ZIP___________________________________________________________________ State of Legal Residence and date you became resident (mm/yy)______________________ Driver’s License Number and Expiration date (mm/yy)________________________________ Phone: (___)_____-______ Fax: (____)______-_________ Email:______________________ Country of Birth _________________________ US Citizen? YES NO Resident alien number (include copy of front and back) ______________________________ Marital status______________________ Will spouse be with you? YES NO Number of children______________ Will children be with you? YES NO Name(s) and age(s) of children: Name of ChildAge Date of Birth Number in your household: ______ Number of college students in your household: _______ Did you file Federal Income Taxes last year? YES NO If yes, which Federal Income Tax Form did you complete? ___________ If no, please fill out the attached Non-tax Filer Form. Will you have your Bachelor’s Degree before July 1? YES NO If yes, what date? ________ Do you intend to be co-enrolled in the MBA Health Care Management Concentration Program through Davenport University? YES NO Have you applied for the St. Matthew’s Academic Scholarship, Y ES NO Have you been awarded a scholarship at this time? YES NO Are you a transfer student? YES NO If yes what semester? _________ When is your start date of attendance: JAN _____ MAY _____ SEPT _____ List ALL Post-Secondary Institutions attended: (Please print legibly) Full Name of Institution (No Abbreviations) City and StateDates attended From-----To----Degree Received Personal References (Please print legibly) NameStreet AddressCity/State/ZipHome Phone By signing this, I certify that all of the information contained on both sides of this form is correct to the best of my knowledge and that if found to be false, may be seen as a violation of the Honor Code. _____________________________ _____________________________ Student Name (print) Student Name (signature) Date Financial Aid Statement of Intent For Payment of Tuition Tuition for St. Matthew’s University School of Medicine is due 15 days prior to the first day of the semester. If tuition is not paid and arrangements are not made with the STUDENT ACCOUNTS OFFICE, you will not be able to continue with your program. I, __________________________, will pay my tuition by __________________ Student name month/day/year I intend to pay my tuition by: Personal check, on_________________________ ISLP/TERI funds, date approved________________ CanHelp/TERI funds, date approved_______________ Health Xpress funds, date approved_________________ Other form of payment____________________________ __________________________ _________________ Student name printed Date ___________________________________ _______________________ Student signature Date ___________________________________ _____________________________ Gloria Miranda-Avila Student Accounts Department Director of Financial Aid Studentaccounts@stmatthews.edu FA@stmatthews.edu Phone: 1.800.678.3301 St. Matthew’s University– Loan Disbursement Authorization I ________________________________________ authorize St. Matthew’s University to disburse my net financial aid loan proceeds as follows; CHOOSE ONLY ONE OPTION OPTION 1: Mail U.S. check to my attention at this address: Street/P.O.Box: City/State/Zip: Phone ___________________________ OPTION 2: Wire Transfer to my US Bank account (attach copy of voided check) Financial Institution Receiving Funds Primary Destination Bank Name: Primary Destination Bank Address: (Include street, city and state) ______________________________________________________ Primary Destination Bank ABA/Routing # _____________________________________(9 digits) Intermediary Bank (if applicable) Intermediary Bank Name: _________________________________________________________ Intermediary Bank ABA#: Intermediary Bank Acct#____________________ Receiving Party’s Information Beneficiary of Account to Credit: (Name of Account Holder) Account Number to Credit: _________________________________(Checking _____ or Savings _____) (For final Credit to) ____________________________________________________________________ OPTION 3: Wire Transfer to my International Bank Account (attach copy of voided check) Financial Institution Receiving Funds Receiving Bank Name: __________________________________________________________________ (Final Destination) Receiving Bank Address: ________________________________________________________________ (Must be complete, include city, state and country) Financial Institution Swift Code or ABA # ___________________________________________________ US Correspondent Bank Name: ___________________________________________________________ (If Applicable) US Correspondent Routing/Transit Number (ABA): __________________________________________ (If Applicable) Receiving Party’s Information Beneficiary of Account to Credit: __________________________________________________________ (Name of Account Holder) Account Number to Credit: _______________________________ (Checking _____or Savings______) (For Final Credit) I understand that a US$25.00 fee will be deducted from my loan proceeds to cover the bank charges for each wire transfer. SIGNATURE: SS# Date: ST. MATTHEW’S UNIVERSITY SCHOOL OF MEDICINE Academic Scholarship Application St. Matthew's University, always in search of excellence, offers a $10,000 scholarship to the most promising candidate for each first semester class. These scholarships are for tuition reduction of $2,000 per semester for the five semesters of basic sciences. To continue to receive the $2,000 each semester, the recipient must remain in the top 20% of his/her class. To be considered for one of these scholarships, you must have completed an undergraduate degree with a 3.5 GPA or higher. The scholarship committee will consider your overall credentials including your college performance, letters of reference, personal statement, community involvement and volunteer work. To apply for this scholarship, you must have paid your $75 application fee and received your letter of acceptance. Name: ___________________________________________________SS#:__________________________ Address: _______________________________________________________________________________ Phone: __________________________________________ E-mail: ________________________________ Undergraduate GPA: ______________ Entry Term: _________________ Personal Statement: Discuss below why you believe you should receive an Academic Scholarship to St. Matthew’s. Include an overview of your academic performance and community involvement as well as any exemplary activities. Letters of reference, certificates of service, and other examples of excellence should be attached and will be considered in the review process. This is not a need-based scholarship, but a scholarship rewarding academic excellence. *NOTE: Failure to attach the personal statement will VOID this application. 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