F&M Committee Letter Application

2014 Entering Class: Medical and Dental School Health Professions Advising

This application must be submitted at least two full business days prior to your Pre-Application Interview (PAI)

Questions? Contact Anya Clark at 358-4191, anya.clark@fandm.edu

Basic Applicant Information
Name: * First Last
Middle Name:
Preferred/Nickname: *
Class Year: *
College House: *
Citizenship: *
State of Residence: *
F&M ID#: *
Permanent Home/Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
F&M Email: *

Enter your full email address.
Other Email:

Enter your full email address.
Cell Phone: - (###) - ### ####
Home Phone: - (###) - ### ####
Applying to: * Allopathic (MD) Medical School Osteopathic (DO) Medical School Dental School
Check all that apply:
Combined Degree Program (specify): *
Have you applied previously? * Yes No
Check all that apply:
If yes, indicate years:
Plan for Gap/Glide Year(s): If you are taking a year or more between F&M and intended matriculation at health professional school, please let us know what you plan to do during this time (if known). If plans are not set, please let us know what you are considering:
Academic Record
Major(s): *
Minor(s):
Adviser(s): *
Cumulative Undergrad GPAs to Date:
BCPM (Science): *
Non-Science: *
Overall: *
Please calculate your cumulative BCPM (biology, chemistry, physics and math), Non-Science, and Overall GPAs. These GPAs must be computed prior to your pre-application interview. Include grades from all college courses taken anywhere. Med school: refer to the Course Classification Guide at the back of the AMCAS Instruction Manual. Dental school: see “Grade Point Averages” under FAQs at www.adea.org/aadsas.
Courses Taken Anywhere Other Than F&M:

List names of schools, dates attended, courses taken, and grades. Please drop off or email us a student copy of your transcript from these schools:
English: *

Please indicate how you have satisfied the English Requirement at F&M. Provide your First-Year Seminar, English courses, Foundations courses, etc.
MCAT (pre-meds only):
Month/year taken or planned to take?
Scores: PS
Scores: VR
Scores: BS
Earlier Attempt: PS
Earlier Attempt: VR
Earlier Attempt: BS
DAT Scores (pre-dents only):
Scores: NS
Scores: PA
Scores: RC
Scores: QR
Earlier Attempt: NS
Earlier Attempt: PA
Earlier Attempt: RC
Earlier Attempt: QR
Honors & Awards:

List scholarships, honor societies, or any forms of special recognition by the College or your major department. Include date awarded and criteria for receiving award (if known):
Withdrawals & Academic Difficulty:

If you have withdrawals or isolated weak grades on your transcript which you feel warrant explanation and context, please take the opportunity to do so here:
Work and Activities
High School:
High School Location (City, State):
Please include all health related experience, extra curricular activities, research, and employment. The formal application services for medical and dental school would like you to include all significant experiences. You may include a few select high school activities, but only from junior and senior year and only those done in depth. Please remember to write out any acronyms for any organizations we haven’t heard of. Please do not feel like you need to complete all fifteen experience fields.
Health-Related Experience

List health-related experiences, including name of organization, location, start and end dates, a brief description of what you did, and whether it was volunteer or paid.
Extracurricular Activities

List athletics, clubs, creative and performing arts, and non-health-related community service. Include name of activity, organization, average hours per week, start and end dates, office(s) held. Make sure to include significant hobbies and interests even if they are not at F&M.
Research

Include location, start and end dates, and brief description of work. Include in your description a brief summary of the significance of the research.
Jobs

List any jobs during academic years, summers, and post-graduation. Include title, organization, location, start and end dates, hours per week, and brief description of duties. Include only jobs not already listed under “Health-Related Experience.”
1. Experience Name/Title
1. Start Date / MM / DD YYYY
1. End Date / MM / DD YYYY
Or Until present
1. Experience Type
1. Total Hours or Average Hours per Week
1. Organization Name
1. Location: City, State, (Country)
1. Experience Description (maximum 700 characters)
2. Experience Name/Title
2. Start Date / MM / DD YYYY
2. End Date / MM / DD YYYY
Or Until present
2. Experience Type
2. Total Hours or Average Hours per Week
2. Organization Name
2. Location: City, State, (Country)
2. Experience Description (maximum 700 characters)
3. Experience Name/Title
3. Start Date / MM / DD YYYY
3. End Date / MM / DD YYYY
Or Until present
3. Experience Type
3. Total Hours or Average Hours per Week
3. Organization Name
3. Location: City, State, (Country)
3. Experience Description (maximum 700 characters)
4. Experience Name/Title
4. Start Date / MM / DD YYYY
4. End Date / MM / DD YYYY
Or Until present
4. Experience Type
4. Total Hours or Average Hours per Week
4. Organization Name
4. Location: City, State, (Country)
4. Experience Description (maximum 700 characters)
5. Experience Name/Title
5. Start Date / MM / DD YYYY
5. End Date / MM / DD YYYY
Or Until present
5. Experience Type
5. Total Hours or Average Hours per Week
5. Organization Name
5. Location: City, State, (Country)
5. Experience Description (maximum 700 characters)
6. Experience Name/Title
6. Start Date / MM / DD YYYY
6. End Date / MM / DD YYYY
Or Until present
6. Experience Type
6. Total Hours or Average Hours per Week
6. Organization Name
6. Location: City, State, (Country)
6. Experience Description (maximum 700 characters)
7. Experience Name/Title
7. Start Date / MM / DD YYYY
7. End Date / MM / DD YYYY
Or Until present
7. Experience Type
7. Total Hours or Average Hours per Week
7. Organization Name
7. Location: City, State, (Country)
7. Experience Description (maximum 700 characters)
8. Experience Name/Title
8. Start Date / MM / DD YYYY
8. End Date / MM / DD YYYY
Or Until present
8. Experience Type
8. Total Hours or Average Hours per Week
8. Organization Name
8. Location: City, State, (Country)
8. Experience Description (maximum 700 characters)
9. Experience Name/Title
9. Start Date / MM / DD YYYY
9. End Date / MM / DD YYYY
Or Until present
9. Experience Type
9. Total Hours or Average Hours per Week
9. Organization Name
9. Location: City, State, (Country)
9. Experience Description (maximum 700 characters)
10. Experience Name/Title
10. Start Date / MM / DD YYYY
10. End Date / MM / DD YYYY
Or Until present
10. Experience Type
10. Total Hours or Average Hours per Week
10. Organization Name
10. Location: City, State, (Country)
10. Experience Description (maximum 700 characters)
11. Experience Name/Title
11. Start Date / MM / DD YYYY
11. End Date / MM / DD YYYY
Or Until present
11. Experience Type
11. Total Hours or Average Hours per Week
11. Organization Name
11. Location: City, State, (Country)
11. Experience Description (maximum 700 characters)
12. Experience Name/Title
12. Start Date / MM / DD YYYY
12. End Date / MM / DD YYYY
Or Until present
12. Experience Type
12. Total Hours or Average Hours per Week
12. Organization Name
12. Location: City, State, (Country)
12. Experience Description (maximum 700 characters)
13. Experience Name/Title
13. Start Date / MM / DD YYYY
13. End Date / MM / DD YYYY
Or Until present
13. Experience Type
13. Total Hours or Average Hours per Week
13. Organization Name
13. Location: City, State, (Country)
13. Experience Description (maximum 700 characters)
14. Experience Name/Title
14. Start Date / MM / DD YYYY
14. End Date / MM / DD YYYY
Or Until present
14. Experience Type
14. Total Hours or Average Hours per Week
14. Organization Name
14. Location: City, State, (Country)
14. Experience Description (maximum 700 characters)
15. Experience Name/Title
15. Start Date / MM / DD YYYY
15. End Date / MM / DD YYYY
Or Until present
15. Experience Type
15. Total Hours or Average Hours per Week
15. Organization Name
15. Location: City, State, (Country)
15. Experience Description (maximum 700 characters)
Have you supported yourself financially, in any way, during college? * Yes No
Check all that apply:
If “yes,” describe briefly how many hours per week you have been employed during the academic year, whether or not this work was part of a financial aid package, and what expenses you have been responsible for:
Preliminary List of Schools

Check the box for each school to which you plan to apply.
Medical School: Allopathic (MD) Medical Schools Alabama, AL South Alabama, AL Arkansas, AR Arizona, AZ Keck-USC, CA Loma Linda, CA Stanford, CA UCLA-Geffen, CA UC Davis, CA UC Irvine, CA UC Riverside, CA UC San Diego, CA UC San Francisco, CA Colorado, CO U Conn, CT Quinnipiac, CT Yale, CT George Washington, DC Georgetown, DC Howard, DC FL International, FL FL Atlantic, FL FL State, FL U Central FL, FL U Florida, FL U Miami Miller, FL U South FL, FL Emory, GA Mercer, GA Morehouse, GA Med College GA, GA Hawaii, HI Iowa, IA Loyola, IL Northwestern, IL Chicago Med: Ros Franklin, IL Rush Medical College, IL Chicago Pritzker, IL Southern Illinois, IL U IL-Chicago, IL Indiana, IN Kansas, KS Kentucky, KY Louisville, KY Tulan, LA LSU Shreveport, LA LSU New Orleans, LA Boston University, MA Harvard, MA Tufts, MA U Mass, MA Johns Hopkins, MD Uniformed Services, MD Maryland, MD Central Michigan, MI Michigan State, MI Oakland U, MI U Michigan, MI Wayne State, MI Mayo, MN U Minnesota, MN Saint Louis University, MO Washington University, MO Missouri Colombia, MO Missouri-Kansas City, MO Mississippi, MS Duke, NC Wake Forest, NC Brody - East Carolina, NC UNC, NC North Dakota, ND Creighton, NE Nebraska, NE Dartmouth, NH Cooper, NJ UMDNJ New Jersey, NJ UMDNJ Robert Wood, NJ New Mexico, NM Nevada, NV Albany, NY Albert Einstein, NY Columbia, NY Hofstra North Shore - LIJ, NY Mount Sinai, NY NY Medical College, NY New York University, NY Rochester, NY Weill-Cornell, NY SUNY - Downstate, NY Stony Brook University, NY SUNY at Buffalo, NY SUNY Upstate, NY Case Western Reserve, OH Northeastern Ohio, OH Ohio State, OH U Cincinnati, OH Wright State, OH Toledo, OH Oklahoma, OK Oregon Health Science, OR Drexel, PA Jefferson, PA Penn State, PA Temple, PA Commonwealth, PA Pittsburgh, PA U Penn Perelman, PA Ponce, PR San Juan Bautista, PR Caribe, PR Puerto Rico, PR Brown, RI Med U S. Carolina, SC South Carolina, SC South Dakota, SD Meharry, TN Vanderbilt, TN East TN State, TN TN Health Science, TN Baylor, TX Texas Tech-El Paso, TX Texas A&M, TX Texas Tech-Lubbock, TX UT Galveston, TX UT Houston, TX UT San Antionio, TX UT Southwestern, TX Utah, UT Virginia Tech Carilion, VA Eastern Virginia, VA Virginia, VA Virginia Commonwealth, VA Vermont, VT Washington, WA Med College Wisconsin, WI Wisconsin, WI Marshall, WV West Virginia U, WV
Check all that apply:
Osteopathic (DO) Medical Schools Alabama COM, AL AT Still, AZ AZ COM, AZ Touro U-CA, CA Western U COM, CA Rocky Vista COM, CO LECOM - Bradenton, FL Nova Southeastern COM, FL PCOM- Georgia, GA Des Moines COM, IA Chicago COM, IL Marian U COM, IN U Pikeville COM, KY U New England COM, ME Michigan State COM, MI AT Still-Kirksville, MO Kansis City COM, MO William Carey U COM, MS Campbell U SOM, NC UMDNJ SOM, NJ Touro U-NV, NV NY COM, NY Touro College - NY, NY Ohio U COM, OH OK State U COM, OK Lake Erie COM, PA Philadelphia COM, PA Edward Via COM, SC Lincoln Memorial, TN U N Texas COM, TX Pacific NW COM, WA West VA SOM, WV
Check all that apply:
Dental Schools Alabama, AL Arizona, AZ Midwestern, AZ Loma Linda, CA UCLA, CA UC San Francisco, CA U of Pacific, CA U Southern CA, CA Western U, CA Colorado, CO UConn, CT Howard, DC Nova Southeastern, FL Florida, FL Georgia Health Sci, GA Southern IL, IL U Illinois Chicago, IL Indiana, IN Iowa, IA Kentucky, KY Lousiville, KY Louisiana State, LA Maryland, MD Boston U, MA Harvard, MA Tufts, MA U Detroit Mercy, MI Michigan, MI Minnesota, MN Mississippi, MS Missouri - Kansas City, MO Creighton, NE Nebraska, NE Nevada - Las Vegas, NV UMDNJ, NJ Columbia, NY New York Univ, NY Stony Brook, NY Buffalo, NY UNC - Chapel Hill, NC Case Western, OH Ohio State, OH Oklahoma, OK Oregon Health Sci U, OR Penn, PA Pittsburgh, PA Temple, PA Puerto Rico, PR Med Univ SC, SC Meharry, TN Tennessee Health Sci, TN Baylor, TX UT Houston, TX UT San Antonio, TX VA Commonwealth, VA Washington, WA West Virginia U, WV Marquette, WI Alberta, CAN British Colombia, CAN Manitoba, CAN Dalhousie, CAN Toronto, CAN W Ontario, CAN Laval, CAN McGill, CAN Montreal, CAN Saskatchewan, CAN
Check all that apply:
Recommenders
From whom shall we expect letters of recommendation?

Two of your letters should be from individuals who taught you science, and at least one of these science instructors must be from F&M in order to be eligible for the committee letter. We recommend 4-6 letters total. Please be aware that, after completing your PAI, the individuals you list as recommenders will be notified, via email, that you have waived your rights of access and the letter will be confidential.
Recommender #1: *

Enter recommender's name, email and organization.
Recommender #2:

Enter recommender's name, email and organization.
Recommender #3:

Enter recommender's name, email and organization.
Recommender #4:

Enter recommender's name, email and organization.
Recommender #5:

Enter recommender's name, email and organization.
Recommender #6:

Enter recommender's name, email and organization.
Request for Letters & Consent to Disclosure

I plan to request letters of recommendation from the persons listed above and consent to these letters being made available to health professional schools. I further request that the Health Professions Advisory & Review Committee prepare a committee letter for me, and consent to Health Professions Advising’s disclosure of this document to the same persons and institutions as my letters of recommendation. I also consent to the use of my recommendations and committee letter in support of my candidacy for relevant prizes, awards, fellowships, or grants for which I may apply. These materials will not otherwise be used without my written consent. Use of my letters for purposes other than those stated above will require approval from each individual recommender. This statement is provided in connection with the Family Educational Rights and Privacy Act of 1974.
Letter Access Waiver: Please read and agree to one of the statements below. The checked circle, along with your typed name and date, will constitute your signature. * These letters are confidential and will not be made available to me without prior consent of the authors. I retain my right of access to these letters. I have discussed this decision with Dr. Cummings.
Name * First Last
Date *
Authorization to Access Information * I give to the Franklin & Marshall Registrar and to other College officials permission to release to Health Professions Advising my transcript and any other information relevant to preparing my committee letter. The checked box, along with my typed name and date, constitutes my signature.
Name * First Last
Date *
Disclosure of Institutional Action
You will see a version of this question again on your AMCAS, AACOMAS, or AADSAS application. Were you ever the recipient of any institutional action by any college for unacceptable academic performance or conduct violation, even though such action may not have interrupted your enrollment or required you to withdraw? You must answer “yes” even if the action does not appear on or has been deleted from your official transcript due to institutional policy or personal petition. * Yes No
If “yes,” please describe the action and circumstances surrounding it:
Do you have a criminal record of any kind, beyond minor traffic tickets? * Yes No
If “yes,” please describe in detail:
Autobiography
Write an essay describing yourself. You might want to pay attention to any of the following topics, but these are only ideas: your family background, your cultural or ethnic background, any activities, experiences, or hobbies you enjoy, especially ones that distinguish you from others (in your view). The content of this essay is very helpful to us when we are writing your committee letter. This is not the personal statement that you will later write for your AAMCAS, AACOMAS, or AADSAS application; however, it is a starting point for that document, an essay where you can begin to work out what you’d like to focus on in the personal statement.

F&M Committee Letter Application

F&M Committee Letter Application

Basic Applicant Information

Academic Record

Cumulative Undergrad GPAs to Date:

MCAT (pre-meds only):

DAT Scores (pre-dents only):

Work and Activities

Health-Related Experience

Extracurricular Activities

Research

Jobs

Preliminary List of Schools

Recommenders

From whom shall we expect letters of recommendation?

Request for Letters & Consent to Disclosure

Disclosure of Institutional Action

Autobiography