SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
BIOGRAPHIC INFORMATION
Student 11/30/2015 5:10 PM
Comment [1]: This section is preformatted; fill in fields accordingly (refer to
sample).
Xavier ID#: 900012345
Year to matriculate: 2018
Date: January 17, 2013
Last Name:
First Name:
Middle Name:
Suffix:
Premed
Joe
Da
Permanent Address-Street:
City:
State:
Zip:
1109 Lee Street
Anyplace
LA
70000
County (if in U.S.A.):
Country (if not U.S.A.):
e-mail:
Orleans
jdpremed@xula.edu
Daytime phone (including area code): Evening phone (including area code): Fax (including area code):
(504) 555-5555
(504) 666-6666
Parents or Guardian
Name
Father:
David D. Premed
Mother:
Patrice T. Premed
Guardian:
NA
Ages of your brothers:
7, 23
Living
Yes
X
X
Ages of your sisters:
14, 27
Names of all Colleges, Graduate and
Professional Schools Attended (list in
chronological order):
Student 11/30/2015 5:17 PM
Comment [2]: Update the date each time
you revise or add info to the application!!!
Occupation
Legal
Residence
(ST)
Education/College (Highest
Level)
Teacher
LA
College
Secretary
LA
High School
No
Secondary School-Name:
New Orleans High
Location:
Xavier University of Louisiana
New Orleans, LA
Southern University-Baton Rouge
Baton Rouge, LA
Dates of
Attendance
(MM/YYYY
to
MM/YYYY)
06/2011 to
Present
06/2012 to
07/2012
to
Location:
New Orleans, LA
Check if
summer
only
Check if
Jr/Comm
College
Grad Year:
2014
Major
Degree
Granted or
Expected
(with date)
Biology
B.S.
May 2018
√
to
1
SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
COURSEWORK
Xavier ID#: 900012345
Last Name
First Name
Middle Name
Premed
Joe
Da
Academic BCPM/AO Academic Term
Number Type
College Name,
Course Name
Status
Year
Location
Xavier University of FR
C
2011
SS
General Chemistry I
1010
Louisiana
New Orleans, LA
C
General Chemistry I Drill
1010D
B
S1
General Biology I
1230
B
General Biology I Lab
1230L
C
General Chemistry I Lab
1011L
C
General Chemistry II
1020
C
General Chemistry II Drill
1020D
AO
Introduction to Literature
1023 H
AO
World Civilizations to 1500
1030 H
AO
University I
1010
AO
Computer Competency Exam
0020
B
S2
General Biology II
1240
B
General Biology II Lab
1240L
C
General Chemistry II Lab
1020L
C
Organic Chemistry I
2210
C
Organic Chemistry I Drill
2210D
AO
Comp & Rhetoric (Credit by Exam) 1010
AO
Introduction to World Literature
2011 H
AO
World Civilizations Since 1500
1040 H
M
Pre-Calculus (Credit by Exam)
1030 AP
M
Introductory Calculus
1070
AO
University II
1020
SO
JR
C
AO
B
B
P
P
AO
AO
AO
B
B
P
P
C
C
C
2012
B
B
AO
AO
M
B
B
AO
2013
SS
S1
S2
S1
S2
Organic Chemistry I Lab
2230L
Fundamentals of Public Speaking
1010
Biodiversity
2000
Biodiversity Lab
2000L
Physics I
2010
Physics I Lab
2010L
Introduction to Psychology
1010
Elementary French I (Credit by Exam) 1010 AP
Elementary French II
1020
Microbiology
2010
Microbiology Lab
2010L
Physics II
2020
Physics II Lab
2020L
Organic Chemistry II
2220
Organic Chemistry II Drill
2220D
Organic Chemistry II Lab
2220L
Genetics
Genetics Lab
Great Books – Philosophy
African American Studies
Calculus II
Cell Biology
Cell Biology Lab
Christian Faith – Theology
3110
3110L
1030
2000
2070
3091
3091L
1100
CC
CC
CC
CC
CC
CC
CC
CC
Suffix
Jr.
Grade
Sem.
hours
A
3
NG
A
A
A
A
NG
A
A
A
P
A
A
A
A
NG
AP
A
B
PC
A
A
0
3
1
1
3
0
3
3
0
0
3
1
1
3
0
3
3
3
4
4
0
B
B
A
A
B
A
A
PC
A
B
B
B
A
A
NG
B
3
3
3
1
3
1
3
3
3
3
1
3
1
3
0
1
Student 3/15/2016 1:36 PM
Comment [3]: This section is preformatted; fill in fields accordingly (refer to
sample). Be sure to separate academic statuses
with a blank row. Since this section should
ONLY take up TWO (2) pages, be sure to
begin entering courses on PAGE 2 once there
are no more rows available on PAGE 1. That
is, rows from PAGE 1 should not force the
creation of an additional page for this section.
NOTE: Include past and future undergraduate
coursework (through graduation) AND
coursework from all colleges and universities
attended. Enter course names and numbers
exactly as they appear on your transcripts.
Before submitting your FINAL application(s),
you must enter your Spring 2016 final grades.
REFER TO SAMPLE APP and “Coursework
Section Notations” of this instruction packet.
Quo Vadis Webster 11/30/2015 5:50 PM
Comment [4]: Separate “Academic Status”
with blank line between FR/SO, SO/JR, JR/SR
(refer to sample).
3
1
3
3
4
3
1
3
2
SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
COURSEWORK (continued)
Xavier ID#: 900012345
Last Name
First Name
Premed
Joe
Academic BCPM/AO Academic Term Course Name
College Name,
Status
Year
Location
AO
Logic – Philosophy
AO
Biblical Studies – Theology
AO
Introduction to Sociology
SR
Grade
Sem.
hours
2040
1120
1010
CC
CC
CC
3
3
3
Introduction to Embryology
Introduction to Embryology Lab
Anatomy & Physiology
Anatomy & Physiology Lab
Introduction to Scientific Literature
Medical Microbiology
Medical Microbiology Lab
Histology
Histology Lab
Biochemistry
Biochemistry Lab
Introduction to Ceramics
Karate
Elementary Linear Algebra
3162
3162L
3350
3350L
4210
3081
3081L
4111
4111L
3130
3130L
1050
2400
2030
CC
CC
CC
CC
CC
CC
CC
CC
CC
CC
CC
CC
CC
CC
4
0
3
1
3
3
1
4
0
3
1
3
3
3
African American Christianity
2000
2014
Southern University SO
Baton Rouge, LA
AO
2012
College Board
AP Program
C
2011
S2
Chemistry w/Lab (Elective)
1***
AO
AO
M
2012
S2
World History
World History
Calculus-A
1030
1040
1030
S2
Suffix
Jr.
Number Type
B
B
B
B
B
B
B
B
B
C
C
AO
AO
M
FR
S1
Middle Name
Da
A
3
AP
TR
8
AP
AP
AP
TR
TR
TR
3
3
4
Student 11/30/2015 5:51 PM
Comment [5]: Enter AP credit accordingly
after you enter all “college” coursework.
Remember, the academic year begins with the
summer/fall session. So, if you were given
credit in Spring 2012 for AP, it goes under the
2011 academic year. See Academic Year
explanation in the “Coursework Section
Notations” section of this instruction packet.
3
SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
POST-SECONDARY EXPERIENCE
(After your Post-Secondary Experiences Form has been reviewed by the Premedical Office at least twice during the current
academic year and revised accordingly by you, just copy and paste it---without the original PSE header and footer---into
this space. Be sure to retain the ORIGINAL PSE formatting! DELETE THIS TEXT and replace it with your PSE. Make sure
there is space between the first table on each page and the application header AND that spacing between tables is consistent
throughout this section.)
4
SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
PERSONAL STATEMENT
(This is probably the most important part of your application so you should put extra time in on it. It cannot be longer than
5300 characters including spaces. Use Times New Roman, 10-12 point font size. After your personal statement has been
reviewed by the Premedical Office at least twice during the current academic year and revised accordingly by you, just copy
and paste it into this space. DELETE this text and replace it with your PS. If, after copying and pasting your PSE Form, this
section is moved down, please move it up to the TOP of the page!!!)
5
Student 11/30/2015 5:05 PM
Comment [6]: Copy and paste your PS
beneath the title “Personal Statement” (after
it’s been critiqued by the PM Office and
revised by YOU multiple times).
SAMPLE Application for St. Louis U, Dartmouth, Tulane, and
U of Rochester Early Acceptance Programs-FINAL APP SHOULD BE PROGRAM SPECIFIC!!!
(BLANK applications for EACH program available at http://www.xula.edu/premed/PMInfo/PMIndex.htm)
CERTIFICATION
1.
Institutional Action: Were you ever the recipient of any institutional action by any college or medical school for
unacceptable academic performance or conduct violation, even though such action may not have interrupted your
enrollment or required you to withdraw? Circle the answer that applies.
Yes
No
2.
Felony: Have you ever been convicted of a Felony? Circle the answer that applies. Yes
3.
Previous Matriculation: Have you ever matriculated at or attended any medical school as a candidate for an M.D.
degree? Circle the answer that applies. Yes
No
4.
Certification: I have read, understand, and agree to comply with the rules of Tulane/Rochester/SLU School of Medicine
and I certify that the information in this application is current, complete, and accurate to the best of my knowledge.
Circle the answer that applies. Yes
No
No
Applicant’s Signature__________________________________ Date ________________________
Student 4/8/2016 12:03 PM
Comment [7]: Header and Last page of
each early acceptance application are
PROGRAM SPECIFIC. Make sure you
submit your FINAL program-specific
application for EACH of the programs you are
applying to. Your signature must appear on
application (mail, email, or deliver in-person).
Final application (s) due in PM Office by May
15th. Final application must include Spring
2016 grades. Be sure to have your draft
application critiqued multiple by Ms.QV
between February 15th and April 30th; no
applications will be critiqued after April 30th.
6