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The more detail we have, the more we can use in the letter. Failure to provide vital information will slow down the entire process. Failure to provide information about experiences that are not a part of your academic record means we simply will not know about those things and cannot refer to them in the letter written for you. Give thorough documentation of honors, research, volunteering, etc. because we have no other source of that information. (For example, which summer did you do that summer program; how long was the program; what was the name of the program?) Add pages if necessary. Be sure that you can DOCUMENT for the medical school anything that you list; they may ask for documentation. If new information becomes available after submission of this form, submit it as an addendum. NAME _____________________________________________________________________ (PRINT) LAST FIRST MI LOCAL ADDRESS ______________________________________________________________ LOCAL PHONE ___________ CELL PHONE _________________email _____________________ HOME ADDRESS __________________________________________________ __________________________________________________ HOME PHONE NO. _________________________ MAJOR: _______________ ACADEMIC ADVISOR: ____________________CURRENT GPA: ________ I hereby give the PHCAP Committee permission to access my academic record. _______________________________ __________ signature date You must supply the PHCAP Committee with the following: 1) A copy of your application's PERSONAL ESSAY. (If you give us a draft of the essay before you submit it, we will provide feedback.) 2) A copy of your MCAT, DAT, OAT (or other) entrance examination scores. (If you release scores to health professions advisor at the time you take the test, that is sufficient.) DATE of Exam: _____________ Did you release scores to Advisor? ___________ SCORES: __________________________________ DO YOU AGREE to the PHCAP Committee's displaying on the PHCAP Bulletin Board an announcement of your acceptance to professional school? ______Yes ______ No. Return materials to: Cynthia Ann Jackson, Chair, PHCAP Committee Department of Biology, ХЗУРИпЧх, Tuskegee, AL 36088 If problems/questions: contact jacksonc@tuskegee.edu or phone (334) 727-8063 or FAX (334) 724-3919 Mr. Wise in 207 Armstrong, (334) 727-8832. HONORS/AWARDS for Scholarship, Citizenship, Athletics, etc (What? When? In recognition of?) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ LEADERSHIP _______________________________________________________________________ HOBBIES, SPORTS, CLUBS, OTHER EXTRACURRICULAR ACTIVITIES (Dates?) ___________________________________________________________________________________ ___________________________________________________________________________________ RESEARCH EXPERIENCE (Where? Name of Program/ Project? Supervisor**? Dates? ) __________________________________________________________________________________ __________________________________________________________________________________ CLINICAL EXPOSURE (Summer enrichment programs, Hospital volunteering, shadowing: Duties? Where?) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ OTHER SERVICE ACTIVITIES NOT CITED ABOVE (Tutoring, volunteering) ___________________________________________________________________________________ ___________________________________________________________________________________ JOBS HELD WHILE A STUDENT (What? Dates? Number hours/week? Responsibilities? ) ___________________________________________________________________________________ HOW DID YOUR DESIRE TO ENTER THIS PROFESSION ORIGINATE? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ANY RELATIVES IN THE HEALTH CARE PROFESSIONS (What relation to you? What professions?) ___________________________________________________________________________________ WHAT WILL BE YOUR SPECIALTY ? ________________ WHERE PLAN TO OPEN OFFICE? ________ ADDITIONAL COMMENTS? 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