Beruflich Dokumente
Kultur Dokumente
PHPBProgramLetterApplication2017EnteringClass
Version1
Nickname:
Middle
Name:
Gender:
Last
Name:
Birthdat
e:
(MM/DD/YYYY)
Email Address:
CSUF:
Personal:
CWI
D:
Local Address:
City
Country
State
Zip Code
Permanent Address:
City
Country
Home
Phone:
State
Zip Code
Cell
Phone:
Will you apply for a fee waiver from the centralized application service?
Yes
No
Did you or a member of your immediate family ever live in subsidized housing?
Yes
No
Did you or a member of your family ever receive benefits from the Federal Free and Reduced Meal p
PHPBProgramLetterApplication2017EnteringClass
Version1
Yes
No
As an undergraduate, were you eligible for need-based financial aid?
Yes
No
No College
Some College
College Graduate
Graduate School
No College
Some College
College Graduate
Graduate School
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 2
Full
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 3
Full
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 4
Full
Name:
Dept/Ins
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Yes
Yes
Yes
No
No
No
PHPBProgramLetterApplication2017EnteringClass
Version1
t:
Contact Info
(email):
RECOMMENDER 5
Full
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 6
Full
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 7
Full
Name:
Dept/Ins
t:
Contact Info
(email):
RECOMMENDER 8
Full
Name:
Dept/Ins
t:
Contact Info
(email):
Requested:
Clinical
Letter?
Yes
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Requested:
Clinical
Letter?
Job Title:
Date
Requested:
Clinical
Letter?
Yes
Yes
Yes
Yes
No
No
No
No
No
Dates
8/24/065/16/10
Program
Level
Undergradu
ate
Major
Biology
Degree
BS
Cum
GPA
3.56
PHPBProgramLetterApplication2017EnteringClass
Version1
Pre-requisites Data
Please fill in the table below with your course work information. If a pre-requisite course was
taken in another institution please put the data from the course equivalent. Please make
sure to include all course attempts. At the end of the table you will be ask to compute your
pre-requisite GPA. For your convenience a link to a GPA calculator has been provided.
Course
Attempt #1
Semester /
Grade
Attempt #2
Semester /
Grade
Attempt #3
Semester /
Grade
University
Pre-requisite GPA*:
* To calculate your pre-requisite GPA please navigate to the following website address:
http://www.fullerton.edu/aac/AACTool/gpa_calculator.asp
PHPBProgramLetterApplication2017EnteringClass
Version1
V.
Entrance Exam
Please input the date of your entrance exam below. Should any changes or updates need to
be made as your application cycle approaches, please be sure to inform Brandy. Once your
scores are available please forward an unofficial copy of them to Brandy and Dr. Goode.
Score (if
available):
(MM/DD/YYYY)
PHPBProgramLetterApplication2017EnteringClass
Version1
VI. Essay
Please provide an essay that discusses what you believe makes you a distinctive candidate
for a career in a health profession. You may also want to discuss specific challenges that
you have faced to reach this point. This should be no more than 5000 characters w/spaces.
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 1
Experience
Name:
Experience
Type:
Dates:
To
Average Hours Per
From:
:
Week:
Organization
Name:
Contact
Emai
Name:
l:
Did this experience involve direct patient interaction? If so, please describe
the patient interaction below.
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 2
Experience
Name:
Experience
Type:
Dates:
To
Average Hours Per
From:
:
Week:
Organization
Name:
Contact
Emai
Name:
l:
Did this experience involve direct patient interaction? If so, please describe
the patient interaction below.
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 3
Experience
Name:
Experience
Type:
Dates:
To
Average Hours Per
From:
:
Week:
Organization
Name:
Contact
Emai
Name:
l:
Did this experience involve direct patient interaction? If so, please describe
the patient interaction below.
In the
EXPERIENCE 1
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 2
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
EXPERIENCE 3
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
EXPERIENCE 2
Experience
PHPBProgramLetterApplication2017EnteringClass
Version1
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
X. COMMUNITY SERVICE
Regarding community service related experiences, provide a general summary of your on
and off campus engagement in community service and volunteering. Highlight your role in
each setting and what you learned.
You may enter up to 3 experiences below. Please enter only significant experiences and
remember that professional schools are more interested in quality than quantity.
In the
EXPERIENCE 1
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 2
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
EXPERIENCE 3
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 1
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
PHPBProgramLetterApplication2017EnteringClass
Version1
EXPERIENCE 2
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
EXPERIENCE 3
Experience
Name:
Experience
Type:
Dates:
From:
Organization
Name:
Contact
Name:
To
:
PHPBProgramLetterApplication2017EnteringClass
Version1
PHPBProgramLetterApplication2017EnteringClass
Version1
PHPBProgramLetterApplication2017EnteringClass
Version1
Date
:
PHPBProgramLetterApplication2017EnteringClass
Version1
(MM/DD/YYYY)
XVII. FERPA
FERPA, the Family Educational Rights and Privacy Act of 1974, is a federal law that pertains
to the release of and access to educational records. The law, also known as the Buckley
Amendment, applies to all schools that receive funds under an applicable program of the US
Department of Education. Go to www.ed.gov/policy/gen/guid/fpco to learn more.
Under FERPA, a school may not generally disclose personally identifiable information from an
eligible student's education records to a third party unless the eligible student has provided
written consent. However, there are a number of exceptions to FERPA's prohibition against
non-consensual disclosure of personally identifiable information from education records. One
such exception is that a school can disclose personally identifiable information from an
eligible student's education records, without consent, to another school in which the student
seeks or intends to enroll.
The sending school may make the disclosure if it has included in its annual notification of
rights a statement that it forwards education records in such circumstances. Otherwise, the
sending school must make a reasonable attempt to notify the student in advance of making
the disclosure, unless the student has initiated the disclosure.
By checking the box to the left, I understand that the PHPB Program of California State
University, Fullerton may disclose personally identifiable information from my records to
schools to which I have applied.
Sign by typing
your name:
Date
:
(MM/DD/YYYY)
Four)
This information is used as necessary to plan for equal employment opportunity throughout the Federal
government. It is also used by the U.S. Office of Personnel Management or employing agency
maintaining the records to locate individuals for personnel research or survey response and in the
production of summary descriptive statistics and analytical studies in support of the function for which
the records are collected and maintained, or for related workforce studies.
Social Security Number (SSN) is requested under the authority of the Executive Order 9397, which
requires SSN be used for the purpose of uniform, orderly administration of personnel records.
Providing this information is voluntary and failure to do so will have no effect on your employment
status. If SSN is not provided, however, other agency sources may be used to obtain it.
Specific Instructions: The two questions below are designed to identify your ethnicity and race. Regardless of
your answer to question 1, go to question 2.
Question 1. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.)
Yes
No
Question 2. Please select the racial category or categories with which you most closely identify by
placing an X in the appropriate box. Check as many as apply.
RACIAL CATEGORY
(Check as many as apply)
DEFINITION of CATEGORY
Asian
Adapted from:
Standard Form 181
Revised August 2005
Previous editions not usable
42 U.S.C. Section 2000e-16
NSN 7540-01-099-3446
PHPBProgramLetterApplication2017EnteringClass
Version1