Palomar College
Bridges to the Future Program
Application Form
Full Name (First, MI, Last): _____________________________________ Gender: ___________
Address:
City, State & Zip Code:
E-mail address:
Phone (home, work, cell, include area code):
Date started college (MM/DD/YY):
Major: ___________________________________
Do you plan to obtain an AA degree before transfer? (Y/N):___ College GPA: _______________
Anticipated 4-yr institution: _________________
Desired ultimate degree (circle one): Associates
Clinical Doctorate
Anticipated Major at 4-yr inst: ___________
Baccalaureate
Combined M.D./PhD
Masters
Research Doctorate
Other professional degree
Anticipated transfer date __________High School from which you graduated:
Are you legally eligible for employment in the United States? * (Y/N): _____
Are you a U.S. Citizen or Permanent Resident?
*
(Y/N): _____*If accepted to the program you will be required to
submit proof of your legal right to work in the United States. In addition, the Bridges program requires that participating students be
either citizens or non-citizen nationals. If you do not fit either of these two classifications, you will be unable to participate in the
program.
Please check the box that best describes your ethnicity (shaded are not considered underrepreset.ed by
Bridges—NIH)
1
2
3
4
5
6
7
8
Asian
Chinese
Asian Indian
Japanese
Korean
Laotian
Cambodian
Vietnamese
9
10
11
12
13
14
15
16
Other Asian
Black
Filipino
Hispanic
Mexican
Central American
South American
Other Hispanic
17
18
19
20
21
22
23
24
American Indian/Alaskan
Guamanian
Hawaiian
Samoan
Other Pacific Island
White
Unknown
Declined to State
After completing the application contact Dan Sourbeer (contact information below) to set up an
appointment to interview for acceptance to the program. Bring the following to the meeting:
1. Unofficial transcripts to confirm good academic standing
2. A personal statement describing your personal and academic background, the reasons for interest in the
program, and your career aspirations
3. At least one letter of recommendation. You may ask the instructor or counselor to send the
recommendation in the form of an email or bring a letter with you.
For questions or to set up an appointment to meet contact Dan Sourbeer at dsourbeer@palomar.edu,
or (760) 744-1150 ext 2775. You can also download more information at
http://daphne.palomar.edu/dsourbeer.
To the best of my knowledge, the information I am supplying is accurate.
______________________
Printed Name
______________________________
Signature
________
Date
Student ID#
Fn=533571254
Rev Aug 03