UT MD/PhD Program at Houston

Secondary Application

For MD/PhD and MD/OMS Applicants

The Secondary Application is required for individuals applying onlyto the MD/PhD only program or the MD/OMS only program at The University of Texas Medical School at Houston (it is not required for individuals who also apply to Medical School thru TMDSAS). After filling out the secondary application, print and send it with a $25.00 fee to the address listed below. Make the check payable to UT Houston Medical School Office of Admissions. Please note your secondary application will not be processed until payment is received. The completed secondary application should be sent directly to The University of Texas Medical School at Houston by November 1, 2016. This information is required to complete the application process.This application fee must be postmarked by November 1stand received by November 15th.

Complete and return to:

The University of TexasMedicalSchool at Houston

Office of Admissions

Attn: Karla Trochez

6431 Fannin, MSB G.400

Houston, Texas 77030

Printed Name: Date of Birth:

The University of Texas Medical School at Houston

Secondary Application for MD/PhD and MD/OMS Applicants

Entry Year 2016

  1. Have you previously applied for admission to any TMDSAS participating medical schools?
    Yes No
    Have you previously applied for admission to any TMDSAS participating dental schools?
    Yes No

If yes, indicate entry year(s) to which you applied to each school:

SCHOOL(s) / YEARS(s) (4 digits in each box)
UT Southwestern MedicalCenter
UT Medical Branch at Galveston
UT HoustonMedicalSchool
UT MedicalSchool at San Antonio
Texas A&M HSC-College of Medicine
Texas Tech HSC-School of Medicine
UNTHSC-TexasCollege of Osteopathic Medicine
UT Dental Branch at Houston
UT DentalSchool at San Antonio
Baylor College of Dentistry-Texas A&M HSC

If you are reapplying, what have you done to strengthen your application? (Limited to 6 lines and 78 characters per line)

  1. What percentage of your college expenses (tuition, room and board and other living expenses) were provided by the following sources: (Please account for exactly 100%)

Family (including spouse) / (3 digits)
Academic scholarships/grants / (3 digits)
Financial need-based scholarships / (3 digits)
Loans / (3 digits)
Jobs/Employment / (3 digits)
Others / (3 digits)
  1. If applicable, what percentage of your living expenses after college have been provided by: (Please account for exactly 100%)

Family (including spouse) / (3 digits)
Employment / (3 digits)
Others / (3 digits)
  1. Has your education or vocation ever been interrupted for any reason?Yes No
    If yes, please explain fully. (Limited to 6 lines and 78 characters per line)
  1. Are you currently under charge or have you ever been convicted of a felony or misdemeanor, other than minor traffic violations, or have you ever received a felony or misdemeanor deferred adjudication? An applicant need not disclose information about a juvenile or criminal record that has been sealed for expunged. Failure to disclose information that is not in fact expunged or sealed may result in the applicant being denied admission. Yes No
    If yes, please explain fully including dates. (Limited to 6 lines 78 characters per line)
  1. Were you ever the recipient of any action by any college or professional school for:
  2. Unacceptable Academic Performance (academic probation, suspension, dismissal, etc.) Yes No
  3. Conduct violations?Yes No

If yes, please explain fully. (Limited to 6 lines and 78 characters per line)

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