INTERNAL APPLICATION FOR ADMISSION
Office use ID #
School of Healthcare Administration and Leadership
 Masters of Healthcare Administration (MHA)
 Healthcare Compliance Graduate Certificate
 Gerontology Certificate
Entry Term & Date:
 Fall 20_____ or  Spring 20_____
Current Pacific University Health Professions student (check one):
 Occupational Therapy  Pharmacy  Physical Therapy  Audiology
 Professional Psychology  Physician Assistant Studies  Speech Language Pathology
PERSONAL INFORMATION
Name: Last ___________________________________ First ________________________________________
Middle ______________________
Other Name(s) used (if applicable): Last: ___________________________ First ___________________________
Middle ________________
Social Security # ______-____-________ Date of birth (Month/day/year): ______/______/______
Email Address _______________________________________________________________________________
Are you a U.S. citizen?  Yes  No (If no, please see International Student Required Statements section below)
Current mailing address________________________________________________________________________
City ____________________________________________
State _______ Zip _________________________
Country ____________________________
Phone: Home ____________________________
Cell ________________________________
Work ______________________________
Background Information: Answers to the following questions are OPTIONAL and are not used by Pacific University in
making decisions.
Gender:  Male  Female  Other: _________________
Ethnic classification:
 Hispanic of any race
For non-Hispanics only:
 American Indian or Alaska Native  Asian  Black or African American
 Native Hawaiian or other Pacific Islander
 White or Caucasian  Two or more races  Other
INTERNATIONAL STUDENT REQUIRED STATEMENTS
If not a citizen of the U.S., are you a Permanent Resident?  Yes  No
Visa Type: _______________________________________
Country of Citizenship: __________________________ Residence: _____________________________
Place of Birth: _____________________________________
EDUCATION
EDUCATION INFORMATION: List all colleges, universities, graduate schools, and professional schools you have attended and/or
currently attending.
Institution
Date
attended
Major
Degree earned
Date
Candidates for admission to the Masters of Healthcare Administration, Healthcare Compliance and Gerontology Graduate Certificate
program(s) must hold a baccalaureate degree from a regionally accredited college or university.
MISCELLANEOUS STATEMENTS
It is in your best interest to answer the following questions fully and to provide more information, rather than less. If you are
uncertain about how to answer these questions, please contact the Office of Admissions. Attach a separate sheet if necessary.
 Yes  No
 Yes  No
 Yes  No
Have you attended Pacific before? If yes, when? _________________________________________
Have you ever been dismissed from, suspended by, or subjected to disciplinary sanctions or reprimands of
any kind by any school, college, or university? If so, attach a detailed explanation on a separate sheet. By
signing this application, you release us to discuss this matter with the school involved should we feel the
need to do so.
How did you first hear of Pacific University? _____________________________________________
How did you first hear about the MHA/BHS/GERO/HCC (circle all that apply) _________________
Who or what influenced you to apply? ___________________________________________________
Have you served in the armed forces? If so, indicate location(s), name, branch, rank, date, and type of
discharge. Attach a separate sheet if necessary.
SIGNATURE
All essays and supplemental statements provided with this application are my own original work. To the best of my knowledge, the
information I have provided in this application is complete and accurate.
Prior to matriculation, I will notify Pacific University if there are any changes to the information I have provided. I also understand that
knowingly providing false information, or failing to provide critical information relevant to this application, may subject me to later
disciplinary action should I matriculate at Pacific University. I have reviewed and meet the Technical Standards on the SHAL website.
Signature ____________________________________________________________________ Date ______________________
APPLICATION REQUIREMENT CHECKLIST
 Application form: Complete and sign.
 Essay: Write an essay no more than two pages describing your professional goals. Include in your
essay how you plan to incorporate leadership in your future career as a health professional.
 Include a current resume
 Please contact Dianna Hall in Financial Aid to update your admissions status. Dianna can be
reached by email: Dianna@pacificu.edu
Please drop off all application Materials or Mail to:
Pacific University Office of Graduate and Professional Admissions
190 SE 8th Avenue, Ste. 181
Hillsboro, OR 97123
FOR OFFICE USE ONLY
 Request Transcript(s) from Graduate Admissions
It is the policy of Pacific University not to discriminate on the basis of sex, disability, race, color, national origin, sexual orientation or age, in admission and access to, or treatment in employment,
educational programs or activities as required by Title IX of the Education Amendments of l972, section 504 of the Rehabilitation Act of l973, Title VII of the Civil Rights act of l964, the Age
Discrimination in Employment Act, the Americans With Disabilities Act of l990 and their implementing regulations.
Students are expected to adhere to the university non-discrimination policy and to the Social Work Code of Ethics in regard to non-discrimination.