Supplemental Application - Oklahoma State University Center for ...

2011 Supplemental Application for Admission
Please complete form online, print and return to the Office of Student Affairs at the address above with your signature. Print a completed
copy for your records. Check printed copy and make sure that all text appears in form boxes.
Social Security Number: _____________
Full Legal Name:
Last: _____________ First: ______________ Middle: ______________ Maiden: _______________
Are you currently or have you ever been known by another name?
No
Yes (please list): __________________________________
Please indicate the ethnicity with which you most identify: _______________________
Legal Residency:
City: _______________ County: _______________ State: ______________ ZIP: _____________
Preferred Mailing Address:
Street: ____________________ City: _____________ State: _____________ ZIP: _____________
Hometown: _______________________
Contact Information: (include area code for each)
Home: _____________ Daytime: _____________ Cell Phone: _____________
Email Address: ___________________________________________
Do you have a family member who is a D.O.?
No Yes (provide name/relationship) ______________________________________
Is your relative an alumnus of OSU-COM?
No
Yes
Check if you are interested in pursuing a dual degree program at OSU-CHS:
D.O./M.B.A D.O./M.S. (Biomedical Sciences) D.O./Ph.D. (Biomedical Sciences)

Have you previously applied to OSU-COM? No Yes (for what years?) _________________
If yes, were you interviewed for admission? No Yes (for what years?) _________________
To what professional schools have you made application this year?
Indicate the name, position or title, address and phone number of each person submitting an
evaluation on your behalf:
a. Name: _____________________________ b. Name: ________________________________
Title: _______________________________
Address: ____________________________
City/State/ZIP: ________________________
Phone: _____________________________
Title: __________________________________
Address: _______________________________
City/State/ZIP: ____________________________
Phone: _________________________________
c. Name: _____________________________ d. Name: ________________________________
Title: _______________________________
Address: ____________________________
City/State/ZIP: ________________________
Phone: _____________________________
Title: __________________________________
Address: _______________________________
City/State/ZIP: ____________________________
Phone: _________________________________
Please provide the following scores:
MCAT: _____________ Current GPA: _____________ Science GPA: _____________
Please attach your responses to the following in a separate document (limit - 2 pages).
1. If not currently in school, describe present activity.
2. Why do you wish to attend the OSU College of Osteopathic Medicine?
3. Is there any additional information you would like the College to know about you?
4. Please attach a picture of yourself on a separate sheet of paper along with your supplemental application

ANY INTENTIONAL FALSIFICATION OR OMISSION OF INFORMATION REQUESTED IN ANY APPLICATION
MATERIALS MAY RESULT IN THE STUDENT'S IMMEDIATE DISMISSAL FROM THE COLLEGE AND FORFEITURE
OF ALL TUITION AND FEES PAID. Having read this notice, I now certify that the information submitted pursuant to
admission to the Oklahoma State University College of Osteopathic Medicine is complete and correct to the best of my
knowledge.
NOTE: The Family Education Rights and Privacy Act of 1974 provides a student access to his/her educational record.
The student retains the right to waive access to specific documents in his/her record.
I do waive my right to access this document and associated supplemental information submitted by person(s) listed above.
I do not waive my right to access this document and associated supplemental information submitted by person(s) listed above.
Signature of Applicant: ______________________________________ Date: _____________
If you are submitting a Bridge Program Application please do not attach it to your Supplemental
Application.