UTSMSA FASTS Application 2009

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The University of Texas School of Medicine at San Antonio

Facilitated Admissions for South Texas Scholars (FASTS) Application

Please type application. Use “Tab” to move forward; “Shift/Tab” to move back / Date
Please check the program(s) you are applying to:
University of Texas – Pan American
St. Mary’s University
Texas A&M International University
1. Personal Data:
Last Name / First Name / MI
Permanent Address / City, State / Zip Code
Current Address / City, State / Zip Code
County / Number of years living at this address / Last 4 Digits of Social Security Number
Telephone Number / () / Email Address
Date of Birth / Place of Birth / Male Female
Are you a Texas Resident / Yes No / How many years have you lived in Texas?
Are you a United States citizen? / Yes No / (If no, Visa TypeNumber)
Ethnicity
2. Educational Data (Please attach an official transcript of your high school and college coursework):
Name of High School / Location of High School
Total student population / Number of students in graduating class
Class Rank / / / Overall GPA / Science GPA / Est. Grad. Date
Total SAT Score / Critical Reading Score / Math Score
Writing Score / Date Taken
Composite ACT Score / English Score / Math Score / Date Taken
Advanced placement (AP) credits, courses and grades:
Concurrent enrollment (CE) credits, courses and grades:
Concurrent enrollment is equivalent to dual-credit courses completed in high school.
3. High School/University Extracurricular Activities (please list):
Activities involved in
Leadership positions held
Honors
Volunteer activities
Clinical experiences
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4. Family History and Data:
Father’s Name / Highest Level of Education
Address / Telephone / ()
Occupation / Employer
Mother’s Name / Highest Level of Education
Address / Telephone / ()
Occupation / Employer
Number of siblings / Ages / Number of siblings attending college

5. Personal Statement:

Please provide a one page typed statement of your educational and career goals with special attention to what you have done to prepare yourself to reach these goals. Also include how participation in the FASTS will assist you in reaching these goals. Remember to type your name at the top of your personal statement.

6. Letters of Reference:

If applying prior to matriculation to one of the participating universities, please provide two letters of reference from: High school counselor

High school science teacher

If applying after matriculation to one of the participating universities, please provide two letters of reference from: University science faculty member

Person (faculty or non-faculty) who is aware of your commitment to a career in medicine

______

7. Résumé: (please attach to application)

8 . Certification of Information and Authorization to Release Records:

I certify the information provided in this application and associated materials are current, complete, and accurate to the best of my knowledge. Per the provisions of the Family Educational Rights and Privacy Act (FERPA), I understand that any personally identifiable information that is collected will be protected.

Signature / ______/ Date

Print application and sign and date above before submitting.

Deadline for application: February 2, 2009. Applications must be postmarked by this date.

Submit to:

Facilitated Admissions for South Texas Scholars Program Committee

Office of Admissions

UT School of Medicine at San Antonio

7703 Floyd Curl Drive – MSC 7790

San Antonio, TX 78229-3900