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Application Form (1)

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8 views

Application Form (1)

Uploaded by

msrisper
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM

Program 4 years MD 5 ½ Year MD (Include Pre Med)

Type Regular Transfer

Semester Applied for January May September

1. PERSONAL INFORMATION
First Name

Middle Name

Last Name

Date of Birth (MM DD YY)

Country of Citizenship Passport No.

Sex Female
Male

Guardian’s Name

Contact No

CURRENT MAILING ADDRESS

City State

Postal Code Country

Permanent Address Same as current mailing address

City State

Postal Code Country

Home Phone Mobile Phone

Email ID
2. ACADEMIC INFORMATION
Existing Qualification High School Diploma Undergraduate

Graduate Other Medical School

List of Institutes Year Major Qualification Grade/GPA/


/ Universities Attended of Completion / Field of Study Percentage

QUALIFYING/COMPETITIVE EXAMINATION FOR MEDICAL EDUCATION

Name of Exam Location(s) Taken Date Attempts (Total) High Score

Specific Undergraduate/Graduate Courses Completed (Prerequisites/Transfer Credits)

List of Institutes Year Major Qualification Grade/GPA/


/ Universities Attended of Completion / Field of Study Percentage

CLINICAL ROTATIONS (FOR TRANSFER STUDENTS ONLY)

Rotation Hospital/University Location Dates Grade Preceptor

Scholarships, awards, distinctions, or


special academic achievements
3. MEDICAL INFORMATION

Do you have any physical disabilities? Yes No

Have you any medical condition or learning disability that No


Yes
may require special attention during medical school?
Are you taking any form of medication prescribed by a Yes No
Physician?

4. SUPPLEMENTAL INFORMATION

If you answered “Yes” to any of the following questions, please submit a full statement of relevant facts for all incidents
along with your application. You may be required to furnish copies of all official documents explaining the final
disposition of the proceedings.
Have you ever matriculated at or attended any medical
school as a candidate for the M.D. Program: Yes No

Were you ever the recipient of any action by any college or medical school for

1. Unacceptable Academic Performance?


(e.g. dismissal, disqualification, suspension, probation, etc.) Yes No
2. Conduct Violations?
Were you ever a party in a civil lawsuit? Yes No

Have you ever been convicted of, or charged with, a felony or Yes No
misdemeanour?

5. HOW DID YOU COME TO KNOW ABOUT AUB

Newspaper Internet Electronic Media Outdoor Advertisement Consultants

Describe the Name of the Source

6. APPLICATION CHECK LIST

All documents must be in English or must have a certified English translation attached and
must be originals or certified copies.

Scanned Copy of Passport - Personal Details Page


Statement of Purpose
2 Letters of Recommendation
IELTS/TOEFL/MCAT/SAT(Optional)
Academic Transcripts
DECLARATION BY THE APPLICANT
I, the above named applicant do hereby declare that, the entries made by me in the
Application Form are complete and true to the best of my knowledge and based on
records. I understand that if any of the information is found wrong my application will
stand cancelled. I, hereby undertake to inform the University, about any changes in
information submitted by me.

By submitting the application, you agree to abide to the laws of the American University
of Barbados whom also is bound by the laws of Barbados.

Place:

Date: Name

Note :
1. AUB is not responsible for arranging a student visa to the USA.
2. AUB students must have all tuition payments applied to their university account to receive
credit.

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