University of Alabama at Birmingham
Pre-Health Applicant Form
Please fill out completely. Make an appointment to turn
this form in to your pre-health advisor :
Office for Pre-Health Advising
CAS Advising
1401 University Boulevard
HHB 402
Birmingham, AL 35294-1152
(205) 934-6135
Applicants for Entry in 2016
In order for the Pre-Health Advising Office to open an official application file for you, you must:
1. Complete this form (TAB through the form fields- Do not hit enter)
2. Print a hard copy
3. Attach a picture in the space provided
4. Attach your personal statement
5. Make an appointment to submit your application prior to February 28, 2015
Please retain a copy for your files.
Please attach a photograph to this page: Applications will not be accepted
without a photograph (you may paste a photo in the form field or include a print)
I understand that the letters of evaluation that I request be sent to the Office for Pre-Health Advising will be placed in a file and
transmitted to one or more professional schools at my direction. The Family Education Rights and Privacy Act of 1974 gives me the
right to inspect these letters unless I waive this right at the time that I request each letter from each evaluator. I understand that all
of my letters will be stamped accordingly. Please note that professional schools prefer the student to waive their rights.
I waive my right of access to all
appraisals and evaluations used in this
process
I do not waive my right of access to all appraisals And
evaluations used in this process.
Signed:_______________________________
Signed:_______________________________
Name:
Name:
Date:
Date:
Student #:
Home Phone Number #:
Pre-: (circle one)
MED DEN OPT
Email:
Cell Phone #:
Work Phone#:
Three evaluations are required from professors or instructors who have taught you and assigned your grade in
a credit course. Two of the three must be in the prerequisite science departments (Biology, Chemistry,
Physics, Math). One may represent your major. At least two must be UAB professors/instructors, one may be
from a previous institution. List below and contact immediately
Instructor
Institution
Course
(office use)
List the schools to which you are applying.
As soon as you receive a request for supplemental applications, please submit a
copy of the request in to this office.
1.
9.
2.
10.
3.
11.
4.
12.
5.
13.
6.
14.
7.
15.
Name:
Address:
City:
Zip Code:
Home Phone:
Student #:
State:
Cell Phone:
Work Phone:
Nickname or Name You Prefer to Be Called:
You are responsible for keeping the above
information current with the pre-health office.
Major:
State/Country of Legal Residence:
Year you plan to enter professional school:
BS/BA date receive(d):
Minor:
Advanced degree - date receive(d)
Parents and Siblings Occupations:
Father
Mother:
Siblings:
*** HIGH SCHOOL ***
High School Attended:
Location
Public/Private?
Size of graduating class
Please list ONE or TWO high school activities that you consider to have been the most rewarding for you.
Briefly explain why they were rewarding.
How did you spend your summers during high school?
*** COLLEGE ***
If you have worked while in college, describe what you did and the number of hours per week that were
involved. Please indicate which, if any, positions were work-study.
When and/or how did you first get interested in healthcare as a career?
What health-related experiences have you had? Specify if they were paid, volunteer, or observation.
Explain how they were meaningful to you.
List your extra-curricular activities:
Explain how they were meaningful to you:
List your community service activities:
Explain how they were meaningful to you:
List any honors you have received:
If your grades are lower than average, state any contributing causes.
If there is a term(s) on your transcript that is not consistent with your other work, please explain.
What is your greatest strength? What is your greatest weakness? Please give examples
The following question appears on the AMCAS/AADSAS/AACOMAS application:
“Were you ever the recipient of any action (e.g., dismissal, disqualification, suspension,
etc.) by any college for unacceptable academic performance or conduct violations?
If “yes” explain fully.
No
Yes
Please indicate above how you will answer the question. If you must answer yes to this
question, please attach a statement of the particulars on a separate sheet about the
situation and discuss the matter fully with the pre-health advisor.
Standardized test scores:
SAT: V
MCAT
Date
M
ACT Composite:
VR
PS
BS
OAT
Date
QR
RC
B
GC
OC
PH
TS
AA
DAT
Date
AA
PA
QR
RC
B
GC
OC
TS
Calculate your GPA(AP and CLEP courses do not count in your GPA, list courses without calculation)
AP/CLEP
Course
Number
Hours
Grade
Quality
BCPM
Name
Points
(Science
GPA)
GPA All
Other
Courses
FR,Year
Course
Name
Number
Hours
Grade
Quality
Points
BCPM
(Science
GPA)
GPA All
Other
Courses
BCPM
(Science
GPA)
GPA All
Other
Courses
BCPM
GPA All
Term GPA
Cum GPA
SO,Year
Course
Name
Number
Hours
Grade
Quality
Points
Term GPA
Cum GPA
JR, Year
Course
Number
Hours
Grade
Quality
Name
Points
(Science
GPA)
Other
Courses
BCPM
(Science
GPA)
GPA All
Other
Courses
BCPM
(Science
GPA)
GPA All
Other
Courses
Term GPA
Cum GPA
SR, Year
Course
Name
Number
Hours
Grade
Quality
Points
Term GPA
Cum GPA
PB,Year
Course
Name
Number
Hours
Grade
Quality
Points
Term GPA
Cum GPA
PB,Year
Course
Name
Number
Hours
Grade
Quality
Points
BCPM
(Science
GPA)
GPA All
Other
Courses
BCPM
(Science
GPA)
GPA All
Other
Courses
Term GPA
Cum GPA
PB,Year
Course
Name
Number
Hours
Grade
Quality
Points
Term
GPA
Cum GPA
PB,Year
Course
Name
Number
Hours
Grade
Quality
Points
BCPM
(Science
GPA)
GPA All
Other
Courses
Term
GPA
Cum GPA
If you do not have enough space to enter all of your courses, create a table in Word and attach it
to this form.