Master of Science in Biomedical Sciences Program
Application Form
Please indicate the program that you are applying for (select only one):
___ Biomedical Sciences Research Track
___ D.O./M.S. Dual-degree Track (associated with the Research Track)
___ Human Anatomy Education Track
Complete all items and return the application, the $60 nonrefundable application fee, and other required materials to:
ATSU Admissions
Biomedical Sciences Application Materials
800 West Jefferson Street
Kirksville, MO 63501
$60 Application Fee: ___ Check or Money Order ___ Credit Card (print credit card payment form)
The Application Deadline is March 1 of the year for entering the program (see Application Instructions).
Full Legal Name ______
Last First Middle
Do you have educational materials under another name? __ Yes __ No
If yes, please indicate name(s) ______
Mailing Address:
______
(Number & Street, Apt. or Box No.)
______
(City, State, ZIP, Country)
______
(Telephone Number)
______
(Email)
Citizen of the U.S.? ___ Yes ___ No
If you are not a U.S. citizen, do you have an I-551 (green card) visa? ___ Yes ___ No
If yes, what is your I-551 (green card) visa and number? ______
What is your country of birth? ______
Have you ever applied to A.T. Still University before? ___ Yes ___ No When? ______
Have you had any U.S. Military experience? ___ Yes ___ No
If yes, what branch: ______
Date and type of discharge: ______
**********************************
* denotes optional information
* Social Security Number: ______
* Gender: ___ Male ___ Female
* Date of Birth (MonthDayYear) :______
* How do you describe yourself (Optional)?___ American Indian or Alaskan Native
___ Black (nonHispanic)
___ White (nonHispanic)
Hispanic (choose only one)
__ Mexican American or Chicano
__ Puerto Rican (Commonwealth)
__ Puerto Rican (Mainland)
__ Other Hispanic / Asian or Pacific Islander (choose only one)
__ Chinese
__ Filipino
__ Hawaiian
__ Indian or Pakistani
__ Japanese
__ Korean
__ Vietnamese
__ Southeast Asian (other than Vietnamese)
__ Other Pacific Islander
__ Other Asian
A.T. Still University does not discriminate on the basis of race, color, religion, national origin, sex, gender, age, sexual preference, or handicap. Such information on the application form is requested solely for the purpose of gathering and reporting applicant flow data or to confirm information used to process the application.
Statement of Past or Pending Disciplinary Actions
1. Have you ever been subject to disciplinary action for academic or other reason(s) in any colleges, universities, or graduate or professional schools you have attended? If yes, please explain.
[ ] No
[ ] Yes ______
2. Have you ever been subject to revocation or suspension of a professional license or been censured, reprimanded, or placed on probation for reasons relating to professional competence or conduct by a state licensing authority? If yes, please explain.
[ ] No
[ ] Yes ______
3. Have you ever had disciplinary action taken against you by any professional society or professional association? If yes, please explain.
[ ] No
[ ] Yes ______
4. Are there any disciplinary charges pending or expected to be brought against you? If yes, please explain.
[ ] No
[ ] Yes ______
5. Is there any information that is relevant to your ability to complete the A.T. Still University program and be eligible for licensure or employment that the University should consider? If yes, please explain.
[ ] No
[ ] Yes ______
I certify that all the statements made in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I know and understand that any or all items contained herein and in the application may be subject to verification and I consent to the full release of all information concerning my capacity and fitness for the educational program by employers, educational institutions, and other agencies. Furthermore, by submitting this application I agree to abide by the policies and procedures as established in the College catalog. A copy may be viewed at www.atsu.edu.
______
Applicant Signature Date
NOTICE OF NONDISCRIMINATION: A.T. Still University of Health Sciences does not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, age, disability, or status as a Vietnam-era veteran in admission and access to, or treatment and employment in its programs and activities. Any person having inquiries concerning ATSU’s compliance with the regulations implementing Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Americans With Disabilities Act of 1990, or other civil rights laws should contact the Director of Human Resources, 800 West Jefferson Street, Kirksville, Missouri 63501 (telephone: 660-626-2790).
Test Score Information (Use the most current test scores)
Complete for all tests that apply.
Test / Month/Year / Test ScoresGRE / Verbal ______/ Quant. ______/ Analytical ______
MCAT / Verbal ______/ Physical ______/ Biology ______/ Writing ______
Verbal ______/ Physical ______/ Biology ______/ Writing ______
Verbal ______/ Physical ______/ Biology ______/ Writing ______
DAT / Math ______
Chem. ______/ Sci. Read. Com. ______
Biology ______/ Visual Percept. ______
Organic Chem. ______
ACT / English ______/ Math ______/ Reading ______/ Science ______
SAT / Math ______/ Verbal ______
I authorize A.T. Still University to maintain all my records under this name.
______
Legal Applicant Signature Date
Letters of Evaluation:
List the name and addresses of the individuals who will write your required letters of evaluation. Your file will not be complete, nor can you be considered for admission, until these required evaluations are received. Applicants may submit letters of evaluation directly in their application packet in sealed, endorsed envelopes. Letters written by relatives to the applicant either by blood or marriage will not be accepted. If the evaluators listed below change, please contact admissions.
EVALUATION #1
______
Last First Middle Degree
______
Academic Rank or Title Department College or University
______
City State Zip Code
______
Telephone Email
I voluntarily waive and relinquish my right of access to this evaluation.______
Applicant Signature Date / I retain my right of access to this evaluation.
______
Applicant Signature Date
EVALUATION #2
______
Last First Middle Degree
______
Academic Rank or Title Department College or University
______
City State Zip Code
______
Telephone Email
I voluntarily waive and relinquish my right of access to this evaluation.______
Applicant Signature Date / I retain my right of access to this evaluation.
______
Applicant Signature Date
Schools/College Attended:
List in chronological order, with most recent first, all undergraduate universities, colleges, and community colleges you have attended. An official transcript from each school/college that you attended must be mailed directly from the institution to the Office of Admissions. Transcript(s) must be received before any action can be taken on your application.
All Undergraduate Schools Attended:
Please enter the FAFSA Code number by accessing www.fafsa.ed.gov/FOTWWebApp/FSLookupServlet.
College Code /Institution
/Campus /
Location /
State
/Inclusive dates of attendance
/ Major / Minor / Degree and Date Degree Granted or Expected / Overall GPAAll Graduate or Professional Schools Attended:
College Code /Institution
/Campus /
Location /
State
/Inclusive dates of attendance
/ Major / Minor / Degree and Date Degree Granted or Expected / Overall GPANote: Failure to list all institutions previously attended or degrees pursued may result in loss of credit and dismissal from the program. Also, if you were previously enrolled in a graduate program that was not completed, please provide a written statement explaining the reasons for noncompletion.
High School Name ______Year of Graduation ______
Location ______
City State
Employment History (starting with most recent):
Employer
/Position
/ DutiesResearch Experience (volunteer or paid; starting with most recent):
Dates Involved /Organization
/Position
/ DutiesTeaching Experience (volunteer or paid; starting with most recent):
Dates Involved /Organization
/Position
/ DutiesPersonal Comments (please type): Provide a brief explanation of your career goals, your interest in biomedical research or teaching and in this program, and highlights of any previous research or teaching experiences. Describe the personal qualities that you will bring to ATSU. If you were directed to provide further explanation to your answers for questions, do so fully here. Include additional pages if necessary.
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Revised: October 17, 2008