Lincoln Memorial UniversityDeBusk College of Osteopathic Medicine
Physician Assistant Program
Supplemental Application
Date of Application: __________________
LMU ID # (if applicable):_________________
Name__________________________________________________________________________________________
Last
First
Middle
Social Security Number ______-______-______ □ Male □ Female
Preferred Name
Date of Birth ______________________
Mailing Address__________________________________________________________________________________
Street
City
____________________________
State
Zip
Telephone____________________________ Email_______________________
County
(Area Code)
Where is your permanent residence: __________________
___________________
State
County
What is your country of citizenship? □ United States □ Other: please specify ________________________
If you are not a US citizen, what is your visa status?
□ Permanent Resident
□ Temporary: please specify____________________
□ I currently do not have a valid U.S. visa.
What is your racial identification?
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Hispanic or Latino
□ Native Hawaiian or other Pacific Islander
□ White (non-Hispanic)
High School Attended:
_______________________
School Name
________________
City
Higher Educational Institutions attended:
City
City
Revised March 26, 2013
City
Graduation date
Major
Degree earned
__________ __________
______
__________ __________
______
__________ __________
______
State
_____________________________________
Name
_______
State
_____________________________________
Name
State
Dates attended
_____________________________________
Name
____
State
1
Graduate Record Examination (GRE) Scores
Date(s)
_________
_________
Verbal Reasoning / Quantitative Reasoning / Critical thinking and analytical writing
________
________
/
/
_______
_______
________
________
/
/
Please list any honors or awards you have received.______________________________________________________
_______________________________________________________________________________________________
Please list any training certifications._________________________________________________________________
_______________________________________________________________________________________________
What is the population of your hometown? □ 1,000,001 or more
□ 500,001 to 1,000,000
□ 100,001 to 500,000
□ 50,001 to 100,000
Are there any health-care professionals in your family?
□ 10,001 to 50,000
□ 5,001 to 10,000
□ 2,500 to 5,000
□ Fewer than 2,500
□ yes □ no
What is his/her family relationship to you? □ Parent □ Sibling
□ Aunt/Uncle □ Grandparent
His/her occupation:
□ Physical therapist
□ Mental-health counseling
□ Other
□ D.O.
□ M.D.
□ Dentist
□ Physician Assistant
□ Nurse
□ Medical technician
□ Other
Specialization: _____________________________________
What is his/her family relationship to you? □ Parent □ Sibling
□ Aunt/Uncle □ Grandparent
His/her occupation:
□ Physical therapist
□ Mental-health counseling
□ Other
□ D.O.
□ M.D.
□ Dentist
□ Physician Assistant
□ Nurse
□ Medical technician
□ Other
Specialization: _____________________________________
What is his/her family relationship to you? □ Parent □ Sibling
□ Aunt/Uncle □ Grandparent
His/her occupation:
□ Physical therapist
□ Mental-health counseling
□ Other
□ D.O.
□ M.D.
□ Dentist
□ Physician Assistant
□ Nurse
□ Medical technician
□ Other
Specialization: _____________________________________
Revised March 26, 2013
2
Please describe your professional experiences.
Job title: ______________________
Field of work:
□
□
□
□
Health-care related
Social-services related
Education related
Legal/Law enforcement
Job title: ______________________
Field of work:
□
□
□
□
□
□
□
□
□
□
□
□
Research related
Business related
Military
Other
Years employed? ____
Health-care related
Social-services related
Education related
Legal/Law enforcement
Job title: ______________________
Field of work:
Years employed? ____
□
□
□
□
Research related
Business related
Military
Other
Years employed? ____
Health-care related
Social-services related
Education related
Legal/Law enforcement
□
□
□
□
Research related
Business related
Military
Other
Please describe significant volunteer experiences.
Organization: _____________________
Field of volunteering:
□ Health-care related
□ Social-services related
□ Education related
Organization: _____________________
Field of volunteering:
□ Community building
□ Arts related
□ Other
Years involved? ____
□ Health-care related
□ Social-services related
□ Education related
Organization: _____________________
Field of volunteering:
Years involved? ____
□ Community building
□ Arts related
□ Other
Years involved? ____
□ Health-care related
□ Social-services related
□ Education related
□ Community building
□ Arts related
□ Other
How do you plan to finance your physician assistant education? (Check all that apply)
□ Loans □ Personal/family funds □ Military scholarship □ Other: Please specify _______________________
Revised March 26, 2013
3
Military experience: □ Yes □ No
If, yes, was your discharge honorable? □ Yes □ No
Branch of service: ____________________
Have you previously attended a physician assistant or medical program? □ Yes □ No
If “Yes”, please specify program _________________________________________________
Please explain reason for leaving program?
Were you ever disciplined for academic performance or conduct violations (e.g. academic probation, dismissal,
suspension, disqualifications, etc.) by any school or college? □ Yes □ No
If yes, please explain.
Have you ever been convicted of a felony or misdemeanor? □ Yes □ No
If yes, please list and date. ____________________
____________________
____________________
_______
_______
_______
How did you hear about Lincoln Memorial University - DeBusk College of Osteopathic Medicine’s PA program?
□ Pre-professional advisor □ D.O. / M.D.
□ PA
□ Osteopathic Medical College
□ Media (TV, Radio, Print) □ AOA
□ AACOM
□ Professional Organization
□ Recruitment Mailing
□ Internet
□ Other _______________________________________
Please list any relatives who have attended Lincoln Memorial University.
__________________________________________
______________________________________________
Name
Name
Relationship
Class
Relationship
Class
__________________________________________
______________________________________________
Name
Name
Revised March 26, 2013
Relationship
Class
Relationship
Class
4
Statement of Past or
Pending Disciplinary Action
Name of Applicant: ______________________________________ Date: ___________________
Have you ever been subject to revocation 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.
□ Yes
□ No
______________________________________________________________________________________
______________________________________________________________________________________
Have you ever had disciplinary action taken against you by any professional society or professional association? If “Yes,” please explain.
□ Yes
□ No
______________________________________________________________________________________
______________________________________________________________________________________
Have you ever been treated for problems with alcohol or drug dependency? If “Yes,” please explain.
□ Yes
□ No
______________________________________________________________________________________
______________________________________________________________________________________
Is there any information relevant to your ability to complete the Lincoln Memorial University DeBusk College of Osteopathic Medicine
Physician Assistant program and be certified for licensure that LMU-DCOM should consider? (Please review the DCOM-PA Program
Technical Standards before answering.) If “Yes,” please explain.
□ Yes
□ No
______________________________________________________________________________________
______________________________________________________________________________________
Revised March 26, 2013
5
CERTIFICATION
I certify that all information provided on this application is true and accurate, complete and correct to the best of my
knowledge and belief, and is made in good faith. I know and understand that any and all items contained herein are
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. I agree that providing inaccurate or
false information or that failure to comply with University policy may result in disciplinary action, including
dismissal. Throughout my enrollment, I agree to comply with the rules and regulations in the Lincoln Memorial
University-DeBusk College of Osteopathic Medicine Physician Assistant student handbook. Finally, I authorize the
people named on my LMU-DCOM Physician Assistant Program Application to provide an evaluation about my
academic performance and/or nonacademic experience relative to my potential for becoming an effective Physician
Assistant.
Signature of Application_____________________________________________Date_____________________
□ I have enclosed a $50.00 non-refundable application fee.
□ I have included an updated resume.
Please return to: LMU-DCOM, Physician Assistant Program, Office of Admissions and Student Advancement, 6965 Cumberland Gap
Parkway, Harrogate, TN 37752
Revised March 26, 2013
6