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Please adhere
Atlantic University School of Medicine
passport
Office of the Registrar
P O Box 456
Island Park, NY 11558
Tel: (516) 368-1700 Fax: (888) 639-0512
photo here.
I. Personal Information
Please print or type
Section A.
Legal Name:
Other Names:
Last
First
Middle
Maiden/Nickname (or any other names that may appear on credentials)
Social Security #:
Title: Mr._ Ms._ Mrs._ Dr._
Date of Birth:
Place of Birth:
Month
Day
Year
City
Country of Citizenship:
State
Country
Male/Female
If not a U.S. citizen, are you a permanent resident?
__ Yes __ No
Preferred Mailing Address:
Street
City
State
Zip Code
Country
Street
City
State
Zip Code
Country
Permanent Mailing Address:
Home Phone:
Work or Day Phone:
Fax:
Cell Phone:
E-Mail:
II. Financial Information
How do you plan to finance your medical education? _____________________________________________________________________________
III. Family Information
Father’s Full Name:
Day Phone:
Mother’s Full Name:
Fax:
Day Phone:
Email:
Email:
Occupation:
Occupation:
Fax:
IV. Academic Information
Indicate the semester you are applying for. Complete only one: January 20
Is this your first application to AUSOM?
Enrollment type desired. Check one:
May 20
September 20
__ Yes __ No
Year Program
MD Freshman
_____ 44-year
____ 6-year MD Freshman
____ Advanced Standing
If you are a transfer student, which school do you currently attend? ________________________________________________
Enrollment Desired: Choose one
How did you hear about Atlantic University School of Medicine? __________________________________________________________
✘ 4 Year Program
_____
_____ 5 Year PreMed/Md
_____ Transfer Basic Science
_____ Transfer Clinic. Science
V. Educational Information
List all high schools, colleges, universities, and graduate schools you have attended.
Institution Name
VI. Transfer
City State or Country
Dates of Attendance
From
To
Major
Degree and Completion Date
or Expected Completion Date
Credits
If you are a transfer student, please list the courses you have taken or are taking.
Course
School
From
To
Grade
Comment
Avalon University School of Medicine reserves the right to accept or deny any applicant.
I understand that Atlantic
I hereby state all information here is true and that (I) / (______________________) am/is responsible for paying all my
fees. I will conform to all the terms and conditions pertinent to being a student/graduate at this school. Any applicant
providing Atlantic
Avalon University School of Medicine with any incorrect or misleading information will be denied admission, be
dismissed, or any degree nullified at any future time.
Please enclose the following along with your completed application: two recent passport-style photographs, two letters of
recommendation, a brief autobiography/ personal essay on medical career expectations, a Curriculum Vitae, official
transcripts from undergraduate and/or graduate colleges, official MCAT scores if taken, letter of good conduct from local
police department, and a non-refundable application fee of $90.00.
Students who are not U.S. citizens are responsible for obtaining their own visas to enter the United States.
Signature_______________________________________ Date ________________________________________________
Email address___________________________________ Mobile Number _______________________________________
This application will not be processed without the $90.00 application fee.
Mail this application to:
Atlantic Admissions Office
P O Box 456
Island Park, NY 11558
What aspects of your life experiences do you think make you a good candidate for medical school?
Who are the three most infuntial people in your life?
What sets you apart from all other applicants to Avalon University School of Medicine?
Optional essay: If you feel like your academic record and or background is somewhat unusual, please state to the Board of Admissions a
concise explanation of your path towards medicine.
How did you hear about Avalon University School of Medicine? (Please be specific)
Advertisement
(Name of Source)_______________________________
School Advisor
(Name of Advisor/School)__________________________________
Reference Book
(Name of Book)_________________________________
Internet
(Name of Site)____________________________________________
AUSOM Graduate
(Name)________________________________________
AUSOM Student
(Name)_________________________________________________
AUSOM Faculty
(Name)_________________________________________
AUSOM Faculty
(Name)_________________________________________________
Were you contacted by phone after requesting information about Avalon University School of Medicine?
Yes____ No____ If yes, please check one: Student____ Graduate____ Admissions____
Did this influence you to apply to Avalon University School of Medicine?
Yes____ No____
Application Fee
Pay by
____Check
___Bank Draft
___Credit Card
Card type _________________________ Expiration Date ______________
Card Number ________________________________________________________
Security Code _____________
Cardholder Name ______________________________________________________________________
Street __________________________________________________ City/Town _________________________________________
State/Province _________ Zip Code _________________ Country _______________
Home Phone Number _________________________________ Cell Phone Number ____________________________________
Work Phone Number __________________________________
Email
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