2016-2017
SUPPLEMENTAL APPLICATION FOR ADMISSION
Mail this form and fee to: University of South Alabama  Department of Physician Assistant Studies
Attn: Admissions Coordinator, 5721 USA Drive North, Room 3124, Mobile, AL 36688-0002
(251) 445-9345  pastudies@southalabama.edu  www.southalabama.edu/alliedhealth/pa
MUST BE POSTMARKED NO LATER THAN OCTOBER 1, 2016
_____________________________________________________________________________
Please print clearly
CASPA ID# _______________________________ Jag No._____________________
(IF Current or Former USA Student)
Full Name ___________________________
Last Name
Male____ Female ____
_________________________________ ________________________________
First Name
Middle Name
Other name in which transcripts may be listed______________________________________________________________________
Current Address ______________________________________________________________________________________________
Street/P.O. Box
City
State
Zip Code
Preferred Telephone (H, C, W) ____________________________________
Birthdate (mm/dd/yy) _____ / ____ / ______
Email Address __________________________________________________________
Our main mode of communication with applicants is by email, and it is the applicant’s responsibility to maintain a functioning email
account, to check it frequently, and to alert the department should any disruption in service occur. By checking this box you affirm
that you have read and agree to the above statement. Yes ______
Have you ever applied to the USA PA Program? Yes No
Have you ever matriculated into a PA program? Yes No
If Yes, Name of School _______________________________
If Yes, why did you not complete the program?___________________________________________________________________
Have you ever applied to or are you a current applicant to Medical (MD) or Osteopathic (DO) School? Yes No
If YES, Application Year(s)________Name of Medical/Osteopathic school?______________________________________________
Have you ever matriculated into Medical School? Yes No
If Yes, why did you not complete the program?_____________________________________________________________________
Have you ever served in the military? Yes No Years of Active Duty_____________ Branch of Service____________________
Date of Entrance___________________ Date of Discharge_____________________ Type of Discharge________________________
Please describe your principal duties in the military__________________________________________________________________
EDUCATION INFORMATION
List information below for each institution (post high school) you attended. Include college, business, trade, and military beginning
with the one most recently attended.
Institution
City/State
Dates Attended
Curriculum/Major
Degree Received
PREREQUISITE COURSES COMPLETED
List only one course for each. Choose a course with the highest grade.
One semester of at least 3 credits is required for the courses below, except for Medical Terminology, which can be 2 credits.
Only courses with a grade of “C” or higher are accepted.
Course
Prefix / No.
Course Name
Course Title
Institution
Grade
Lecture/Lab
Total
Credit
Hours
Year
Completed
Biology
Chemistry I
Chemistry II
Organic Chemistry
Microbiology
Anatomy OR A&P I *
Physiology OR A&P II *
Mathematics
Statistics
Psychology
Medical Terminology+
*
+
Either separate courses in Anatomy and Physiology, OR courses in Anatomy & Physiology I and II can fulfill these. Mixing the sequences
will not fulfill the prerequisites and will not be accepted.
Medical Terminology courses must be at least 2 credits.
BONUS COURSES COMPLETED
List only one course for each. Choose the course with the highest grade.
Bonus courses are not required, but if completed, applicants will receive extra points.
Only courses with a grade of “C” or higher are accepted.
Course
Prefix / No.
Course Name
Course Title
Institution
Grade
Credit
Hrs.
Year
Completed
Immunology
Genetics
Biochemistry
Physics
Pathophysiology
Pharmacology
PREREQUISITE COURSES NOT YET COMPLETED
List only one course for each. Only courses with a grade of “C” or higher are accepted.
Courses can be in progress as long as they are completed before matriculation in mid-May.
Course Name
Course
Prefix / No.
Course Title
Institution
Grade
Credit Year Planning
Hrs. to Complete
IP
IP
IP
IP
IP
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 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 by the University.
___________________________________________________________________________________
Signature
______________________________________________
Date
UNIVERSITY OF SOUTH ALABAMA
Department of Physician Assistant Studies
SUPPLEMENTAL APPLICATION PAYMENT FORM
2016-2017
Complete and mail payment with Supplemental Application.
Please keep a copy for your records.
Please Note:
1.
2.
3.
4.
5.
Personal checks, money orders and cashier’s checks are accepted, please do not send cash.
Please make payable to “University of South Alabama PA Program”.
All application fees are non-refundable.
Payment must be included with Supplemental Application.
Payment and Supplemental Application must be postmarked by October 1, 2016.
Date ___________________
Applicant Name:
CASPA ID Number:
__________________________________________________
_______________________________________________________
Payment: Check or Money Order No.:________________________________________
Amount:
$110.00
By initialing, I understand that no submitted fees will be returned. _______________