University of Houston
HPAC File
(Health Professions Advisory Committee)
REQUEST TO ESTABLISH A PREMEDICAL/PREDENTAL FILE
AUTHORIZATION TO BILL FOR PRE-HEALTH PROFESSIONS
SERVICES FEE
Last name
First name
UH ID
Current UH major (or PB if applicable)
Street address
Apt #
City
State
Cell phone number
Email address
Zip code
I hereby request that the Pre-Health Professions Office establish a personal file on my behalf.
This file will contain items relevant to my application for medical or dental school. I waive
my right to view the contents of my file and authorize the Pre-Health Professions Office to
bill me $25.00 for the Users Services Fee. I understand that this fee will be used to support
the cost of maintaining my file, photocopying documents in my file, and mailing or uploading
letters to professional schools or services. I also understand that this fee is non-refundable.
Signature
Date