Student Supplement to the Committee LOR Interview
Name_______________________________________ SS#_______________________ DOB_____________
Major (s)_________________Minor(s)______________ Are you in the pre-med program?________________
AMCAS/AACOMAS/PCAS/CASPA ID, if assigned _______________________________________________
Summer Contact Info:
Physical Address__________________________________________________________
Email Address____________________________________________________________
Cell Phone Number _______________________________________________________
Type of school to which you are applying (i.e., medical, osteopathic medical, dental, etc).
Are you planning to take a year off? If so, your portfolio should be as complete as possible before graduation.
It is your responsibility to notify me of changes in contact information.
Are you requesting a committee letter (LOR) or a letter packet? _____________________________________
Admission Test you have/will be taking (i.e., MCAT, GRE, PCAT, etc.)__________
Test Date _________________
Score (if taken) _________________
Score Range ______________
Scholarships Received and Dates (Give specific information about the basis on which you were granted nonMessiah Scholarships and renewal information for Messiah scholarships).
Scholarship Name
Dean’s
Emerging Leadership
Honor’s Program
Provost’s
Multicultural
Others
Years Rec’d / Details
Are you a member of Sigma Zeta or another honor society? ____ If so, what year were you inducted? _____
Have you been named to the Dean’s List?
If so, which semesters?
Are you planning to submit additional letters of recommendation? If so, provide details.
Check your PIF to make sure that I have specific information about your co-curricular, research and medically
related experiences. I need details, such as a complete description of your involvement, when you were
involved (i.e., fall, 2009 – present or fall, 2008 – spring 2010), your supervisor’s name, hours worked, etc. I
may wind up quoting you, so please submit any additions or corrections with this paper.
I will need the following materials at the time of our meeting or shortly thereafter BEFORE I begin your letter:
1. A copy of all of your unofficial transcript(s) that includes spring , 2010 grades
2. A copy of your completed application
3. Admission test scores (please notify me by email and then follow up with an official score report)
Note: Failure to follow PHPAC procedures and timelines may result in a letter packet, rather than a committee
LOR, being sent.
Please bring this completed form to your Committee Interview.
Updated 4/11