Application Form - 4 Year M.D. Program in English - Karol Marcinkowski University of Medical Sciences, Poznañ, Poland

AKADEMIA MEDYCZNA IM KAROLA MARCINKOWSKIEGO
ul. Fredry 10, Poznan 60-701, POLAND

(USA OFFICE): 108 Village Square, #402
Somers, NY 10589-2305, +1 (888) 251-6659

EUROPEAN M.D. PROGRAM APPLICATION FORM
FOR THE 200__ ENTERING CLASS

PLEASE COMPLETE THIS APPLICATION AND SUBMIT BY MAIL

PLEASE PRINT OR TYPE

I. BIOGRAPHICAL DATA

1. Social Security Number: __ __ __ -- __ __ -- __ __ __ __

2. Place and Date of Birth:

____________ ___/___/___

3. Last Name: ____________________________ First Name: ___________________ Middle: ____

4. Please check one box:

I am a citizen of the United States
A permanent resident of the United States
A citizen of Canada
A landed immigrant of Canada
Other (please explain): _____________________________________

5. Permanent Address

Street: __________________________

City: ____________________________

Zip and Country: __________________

Phone: (_____) _____--_______

Mailing Address

Street: __________________________

City: ____________________________

Zip and Country: __________________

Phone: (_____) _____--_______

6. Family:

Name	Alive?	Occupation	Legal Residence	Education
Father: _______________________	_____	_________	____________________	____________
Mother: ______________________	_____	_________	____________________	____________
Other Guardian: ________________	_____	_________	____________________	____________
Spouse: ______________________	_____	_________	____________________	____________

7. Siblings. Ages of your brothers: ______________________ Ages of your sisters: ____________________________

8. Dependents. Ages of your dependents: _____________________________________________________________

ACADEMIC DATA

1. Secondary School

Name: _________________ City, State, Province: ______________________________ Year Graduated: __________

2. College(s). Please include Graduate and Professionl Schools. Start with most recent attended.

Name

__________________________

Dates Attended

________________________

Major

_________________

Degree received or expected?

_______________________

III. ACADEMIC WORK RESUME

1. MCAT Scores (if applicable)

Date(s) Taken: ______________	Verbal Reasoning: ______________	Physical Sciences: ______________
Writing Sample: _____________	Biological Sciences: _____________	Number of MCATs Taken: ________

2. Pre-Medical Coursework

Course

*General Chemistry
*Organic Chemistry
Biochemistry
Physiology
*Physics
*Biology
Genetics
Zoology
Histology
Descriptive Geometry
Calculus
Differential Equations
Statistics
*English
* = required course

School

Grade

___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________
___________

IV. PERONAL DATA

1. Please describe any honors that you received during college. Include honorary societies.

2. Describe your extracurricular, community and avocational activities while in college, and after.

3. Were you employed during the current school year? Please list type of work and hours per week.

4. Were you employed during previous school years? Pleace listy type of work and hours per week.

5. How have you spent your summers during your college years?

6. If your education to date has not been continuous, or has already been completed, what have you done while
not in school?

7. Two (2) letters of recommendation are to be sent directly to the USA office.

Use this space for any personal comments which you feel would assist evaluation of your application. These comments
must not exceed the space provided.

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Signature