CHRISTOPHER NEWPORT UNIVERSITY EARLY ACCEPTANCE APPLICATION TO THE
EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE – VIRGINIA AND CAROLINAS CAMPUS
BIOGRAPHICAL INFORMATION:
Last Name
_______________________________________________________________________
First Name
Middle Name
Preferred Name
SSN
DOB
CONTACT INFORMATION:
Current Mailing Address
_________________________________________________________
Permanent Home Mailing Address
Current Phone
Permanent Phone
Cell Phone
E-mail Address
CAMPUS PREFERENCE: Please choose only one
Virginia campus ______OR Carolinas campus ______
Interviews (for those who are eligible) will be conducted at the campus you designated above. Offers of admission will
be made for attendance on that campus, as well. While students may request a change of campus after an interview or
after an offer is made that request is neither automatic nor guaranteed.
What country were you born in?
IF YOU WERE BORN OUTSIDE OF THE UNITED STATES:
At what age did you come to the United States?
Are you a U.S. Citizen?
Yes
Are you a Permanent Resident?
Yes
If you are a Permanent Resident, what is Green Card number?
Please submit a copy of your Green Card with this Application.
Other (please explain)
When do you expect to complete your bachelor’s degree at
Christopher Newport University?
When do you expect to matriculate to VCOM?
No
No
__________
Month
___________
Year
August
___________
Year
COLLEGE MISSION:
VCOM is dedicated to educating students in many fields. Those disciplines in shortage in Virginia, the
Carolinas, and the Appalachian region are of particular interest to VCOM. Please prioritize your current
top three (in numerical order) of the specialties listed below. Please be advised your response does not
guarantee or exclude admission.
Family Medicine
Pediatrics
Internal Medicine
Emergency Medicine
Psychiatry
OB/GYN
Medical Research
Mission Medicine
Public Health
COMMUNITY BACKGROUND AND PREFERENCE:
Which best describes your experience in a rural area (defined as less than 25,000 people and greater
than 30 miles from a population of greater than 100,000)? You may use this URL as a guide:
http://ims2.missouri.edu/rac/amirural/
Please check one.
I have never lived in a rural area
I have spent up to a year living in a rural area
I have spent one to five years living in a rural area
I have spent more than five years living in a rural area
Is your permanent address (or area you identify you are from) in one of the counties in Appalachia? Click Here for a
listing of counties.
Yes
No
Where did you complete middle school?
State
County
Where did you attend the majority of high school?
State
County
Where do you currently reside?
State
County
Legal residence:
State
County
City
City
City
City
Size of community where you completed middle school: Please check one.
<10,000
10,000 – 29,999
30,000 – 49,999
50,000 – 99,999
>100,000
Size of community where you completed a majority of high school: Please check one.
<10,000
10,000 – 29,999
30,000 – 49,999
50,000 – 99,999
>100,000
What is your preference of a community size: Please check one.
<10,000
10,000 – 29,999
30,000 – 49,999
50,000 – 99,999
>100,000
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UNDERREPRESENTED IN MEDICINE:
VCOM recognizes the gaps in medical care that exist in the United States and is committed to a diverse
student body to promote diversity in physician providers in the future. VCOM has been listed as one of
the top schools for Hispanic students and promotes consideration for all under-represented minorities.
At the same time, VCOM does not discriminate against non-minority applicants.
Do you consider yourself a minority applicant?
Yes
No
If you consider yourself a minority applicant, in what capacity?
Disadvantaged Background – Family Income
Disadvantaged Background – Rural Community
Under-represented minority (please indicate below)
African American
Hispanic
American Indian
Filipino
Other (please identify)
MISSION MEDICINE BACKGROUND AND INTEREST:
Have you ever attended a U. S. mission or relief trip?
Yes
No
Have you ever attended an international mission or relief trip?
Yes
No
How would you rate your mission medicine interests? (On a scale of 1 to 5)
1 = No interest
3 = Interested in learning more
5 = Planning on participating
Interest in participating in Appalachian missions:
1
2
3
4
5
Interest in participating in International missions:
1
2
3
4
5
LANGUAGE FLUENCY:
Check the languages with which you are able to communicate:
Spanish
French
German
Chinese
Other (please identify)
Indian Dialect
Vietnamese
PREVIOUS STANDARDIZED TEST SCORES:
ACT SCORE: Taken _____Not Taken ______
Score _______Do Not Recall Score _______
SAT SCORE: Taken _____ Not Taken ______
Score- Verbal: ______Math: ______Writing:______ Do Not Recall Score ______
MCAT:
Taken _____ Not Taken _______ (If not taken, when do you plan to take? ___________)
Score- Verbal: ______ Physical: _______Biology: ______Writing:______
BIOMEDICAL AND CLINICAL RESEARCH INTEREST:
1 = No interest
3 = Interested in learning more
Interest in participating in research as a student:
1
2
3
Interest in participating in Research track
1
2
3
5 = Planning on participating
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4
5
4
5
VOLUNTEER EXPERIENCE:
Which best describes your past level of volunteering within the healthcare field?
Less than 50 hours
51 – 100 hours
101 –200 hours
Greater than 200 hours
Which best describes your past level of volunteering in fields outside of healthcare?
Less than 50 hours
51 – 100 hours
101 – 200 hours
Greater than 200 hours
DESCRIPTION OF WORK EXPERIENCE AND VOLUNTEER ACTIVITIES:
List healthcare, and/or research experiences and volunteer activities beginning with the most recent.
Location
Date
Hours/week
Description
(city, state) (month/year)
VCOM ALUMNI, STUDENTS, AND FACULTY/STAFF:
Do you have a connection with any VCOM alumni, current students, and/or faculty members? If so,
please list their names and the nature of your relationship (ex. shadowing, previous faculty, relative,
etc).
Name
Relationship
MEDICAL ADVISORS:
Please insert a check next to those who guided your decision to pursue a career in medicine.
Family Member
College Advisor
Family Friend
Personal Physician
Personal Friend
List the names/ relationship of any physicians who guided your decision to pursue a career in medicine.
Osteopathic Physicians
Name
Relationship
Name
Relationship
Allopathic Physicians
What is the medical degree of your personal physician?
DO __________MD __________ Have no physician _________ See another health care professional ________
Have any of your family members been treated by a DO?
YES _____ NO_____
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.
HEALTH REQUIREMENTS AND TECHNICAL STANDARDS:
Each student must read the health requirements and technical standards to assure you have the ability
to succeed in a medical curriculum. VCOM is committed to a diverse student body and does not
discriminate on the basis of gender, color, race, age, religious belief, sex, ethnicity, national origin, or
disability. VCOM is committed to providing reasonable accommodations for students to be successful in
the curriculum. Please assure you meet the health and technical standards by reading them on the
VCOM website. If you have questions as to whether or not you meet the standards, you may contact
the Assistant Vice President for Student Services and he will direct your question to the appropriate
area.
By typing my name below, I certify that I have read and that I meet the minimum health requirements
(http://www.vcom.vt.edu/catalog/healthreq.html) and technical standards
http://www.vcom.vt.edu/catalog/technical.html) for admission.
(Typed Name)
(Date)
NOTICE OF NONDISCRIMINATION:
The Edward Via College of Osteopathic Medicine recognizes, values, and affirms that diversity
contributes richness to the college and enhances the quality of education. Students, faculty, staff, and
administrators are valued for their diversity. The College is committed to providing an academic and
employment environment in which students and employees are treated with courtesy, respect, and
dignity. It is the policy of the College that no student or employee shall be excluded from participating
in, be denied the benefits of, or be subjected to discrimination in any program sponsored by the College.
The College's commitment to the principle of nondiscrimination includes and extends far beyond the
federally protected classes of age, ethnicity, gender, race, sex, color, national origin, religion or
handicap. The college has a commitment to nondiscrimination against any individual or group of
individuals. The college has a zero tolerance to inappropriate behavior exhibited as an act of
discrimination. This commitment extends to any individual or any group that may feel disadvantaged
from a social perspective. (See notice of non discrimination in the VCOM student handbook.)
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ESSAY QUESTIONS:
Please answer the following questions and limit your response to one-half page.
What are the top five qualities you feel you bring to VCOM that would enhance the overall climate of
our college?
Osteopathic medicine parallels allopathic medicine but has principles and practices that are distinct.
Which of these principles and practices are of greatest interest to you and why?
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STATEMENT OF PAST/PENDING DISCIPLINARY ACTION:
Have you ever been subject to revocation or suspension of a professional license, been censured,
reprimanded, or placed on probation for reasons relating to professional competence or conduct by a
state licensing authority?
Yes
No
If yes, please explain.
Have you ever had disciplinary action taken against you by any professional society or professional
association?
Yes
No
If yes, please explain.
Have you ever been subject to disciplinary action for academic or other reasons in any of the colleges,
universities, graduate, or professional schools that you attended?
Yes
No
If yes, please explain.
Are there any disciplinary actions pending or expected to be brought against you?
Yes
No
If yes, please explain.
Page 7
Have you ever been charged with a misdemeanor or felony (whether or not you were convicted)? If yes,
specify if you were or were not convicted of the charge. If you were not convicted, list what the status of the
charge is. This includes traffic violations but excludes parking violations.
Please be advised that hospitals where you will complete your clinical training require a background check
and this background check is obtained prior to matriculation and again during your enrollment at VCOM.
Failure to provide accurate and complete information including all charges (whether or not you were
convicted) or previous or pending misdemeanor or felony charges which resulted in a conviction, may result in
revoking your offer of admission or placement of stipulations on your offer of admission. Additionally, if you
have a new charge since completing this application or a pending misdemeanor or felony which results in a
conviction, it is your responsibility to immediately inform VCOM. Note that new charges or convictions could
impact your offer of admission or result in stipulations being placed on your offer.
Yes
No
If yes, please explain and specify if you were or were not convicted.
Is there any information that is relevant to your ability to complete the osteopathic medical education
program at the Edward Via College of Osteopathic Medicine and to be certified for licensure that the College
should be aware of?
Yes
No
If yes, please explain.
By typing my name below, I certify that all information provided to the Edward Via College of
Osteopathic Medicine on this application and all supporting documents and future application materials
is complete and accurate to the best of my knowledge. I know and understand that any and all items
contained in the aforementioned materials 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,
CNU and other educational institutions, and other agencies. Furthermore, by submitting this
application, I agree to abide by the policies and procedures as established in the VCOM College Catalog
and Student Handbook. I acknowledge that falsification or misrepresentation of any materials now or in
the future (including as a candidate, applicant, student, or graduate) or failure to comply with the
policies and procedures will result in review by the Honor Council and/or the Professional and Ethics
Standard Board and/or could result in disciplinary actions up to and including immediate dismissal.
Typed Name
Date
Page 8