TOURO UNIVERSITY

COLLEGE OF OSTEOPATHIC MEDICINE

SUPPLEMENTAL APPLICATION

Mare Island Campus

1. SOCIAL SECURITY NUMBER - - 2. DATE OF BIRTH / / APPLICATION FEE CONFIRMATION NUMBER

3A. LAST NAME FIRST NAME MI

3B. DO YOU HAVE ACADEMIC OR LEGAL RECORDS AVAILABLE UNDER A DIFFERENT NAME WITHIN THE LAST SEVEN(7) YEARS? YES NO (If yes, please provide any additional names under which your records may appear:)

4A. PREFERRED MAILING ADDRESS:

4B. HAVE YOU RESIDED AT THIS ADDRESS FOR AT LEAST SEVEN (7) YEARS? YES NO (If no, please attach a seperate sheet of paper and list all of your previous addresses for the last seven (7) years.)

5. TELEPHONE () - E-MAIL ADDRESS

6. HAVE YOU PREVIOUSLY INTERVIEWED AT TUCOM? YES NO (If yes, attach an additional sheet of paper detailing the result of the interview(s) and what changes, if any, you have made since then which should affect a different outcome)

7. GENERAL DATA:

-U.S. CITIZEN OR PERMANENT RESIDENT YES NO

-UNDERGRADUATE DEGREE DATE (YEAR)

-GRADUATE SCHOOL DEGREE DATE (YEAR)

 

-SIZE OF HOME TOWN OR AREA (Select what best describes your Home Town or Area)

Metropolitan area (500,000 – 1,000,000 +) City (100,000 – 500,000) City (50,000 – 100,000)

City or town (10,000 – 50,000) City or town (2,500 – 10,000) Other, please specify

8. HAVE YOU APPLIED TO TUCOM BEFORE? YES NO IF YES, WHEN?

9. WHAT AWARD(S) OR RECOGNITION(S) HAVE YOU RECEIVED IN COLLEGE?

10. HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR? YES NO

(If yes, provide a brief explanation of the conviction on a separate sheet of paper)

11. LIST YOUR FAVORITE HOBBIES AND/OR NON-ACADEMIC INTERESTS:

12. EMPLOYMENT EXPERIENCE DURING THE LAST THREE YEARS: (MOST RECENT EXPERIENCE FIRST)

PLEASE LIST EMPLOYER NAME, OCCUPATION/POSITION AND THE DURATION OF EMPLOYMENT

13. VOLUNTEER EXPERIENCE, IF ANY, DURING THE LAST THREE YEARS: (MOST RECENT EXPERIENCE FIRST)

PLEASE LIST THE TYPE OF ACTIVITY, SPONSOR, DURATION OF SERVICE AND YOUR POSITION

14. ARE YOU BI-LINGUAL? YES NO IF YES, LIST LANGUAGES IN WHICH YOU ARE FLUENT:

15. EXPLAIN WHY YOU HAVE CHOSEN TO APPLY TO TOURO UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE:

16. WHY SHOULD THE ADMISSIONS COMMITTEE ACCEPT YOU INTO THIS YEAR'S CLASS?

17. LIST ANY RELATIVE WHO IS AN OSTEOPATHIC PHYSICIAN:

PLEASE LIST THEIR NAME, RELATIONSHIP TO YOU, OSTEOPATHIC MEDICAL COLLEGE ATTENDED AND YEAR GRADUATED.

18. PROVIDE A ONE PAGE, COMPUTER-GENERATED RESPONSE TO EACH OF THE FOLLOWING PROMPTS. PLEASE NUMBER EACH RESPONSE SEPERATELY. EACH RESPONSE SHOULD BE A MINIMUM 12 POINT FONT AND MAY BE SINGLE OR DOUBLE SPACED.

1. Describe the personal characteristics you possess and the life experiences you have had that would contribute to your becoming an outstanding osteopathic physician. Please include information that will enable the Admissions Committee to understand your unique qualities.

2. Describe your exposure to and understanding of Osteopathic Medicine. Content may include your initial introduction to the profession, its history, use in medical practice today, or any other aspects that may highlight Osteopathic Medicine's uniqueness and synergy with your envisioned future practice of medicine.

NOTICE: ALL MATERIALS SUBMITTED BY APPLICANTS BECOME THE PROPERTY OF TUCOM. MATERIAL SUBMITTED BY APPLICANTS WHO ARE NOT ACCEPTED FOR ADMISSION IS DESTROYED THREE MONTHS AFTER THE CLOSE OF THE ADMISSIONS CYCLE. INFORMATION GATHERED IS USED SOLELY FOR ASSESSING APPLICANT QUALIFICATIONS AND IS NEITHER SHARED NOR TRANSMITTED OUTSIDE THE OFFICES OF TOURO UNIVERSITY COLLEGE OF OSTEOPLATHIC MEDICINE.

CERTIFICATION STATEMENT: I certify that the information that I have recorded in my supplementary application as well as my personal statement, is accurate to the best of my knowledge. I recognize that any intentional misrepresentation on my part may cause me to be denied admission or subject me to dismissal from Touro University College of Osteopathic Medicine in the event I was accepted.

NAME : DATE : //

SIGNATURE : ___________________________________

 

 

Touro University College of Osteopathic Medicine

California

Technical Standards Certification

 

TUCOM-California is committed to ensuring that otherwise qualified disabled students fully and equally enjoy the benefits of a professional education. TUCOM-California will make reasonable accommodations necessary to enable a disabled student who is otherwise qualified to successfully complete the degree requirements in Osteopathic Medicine. However, TUCOM-California insists that all students meet the minimum essential requirements for the safe, efficient and effective practice of Osteopathic Medicine. Please read the Technical Standards for Admission found in the catalog.

 

I, , hereby certify that I have read the above mentioned portions of the TUCOM-California catalog and that I can meet all requirements listed therein, either without accommodation or with reasonable accommodation from the university. I further certify that I have read, understand, and agree that I am required to actively participate in all Osteopathic Manipulative Medicine Laboratories, which includes but is not limited to both palpating and being palpated by other students, faculty, and other individuals as assigned, as detailed in Section 9 of the Technical Standards for Admission.

 

Signature: _________________________

Date: //

 

PARENT INFORMATION

Touro University occasionally seeks the involvement of parents in governance and advisory boards, projects of the parents network, and support. Providing this information is optional.

Student Name:

 

Fathers Name: Title of Address: (Mr., Dr., Etc.)

Preferred Phone Number: Preferred Email Address:

Home Address:

Employers Name: Employment Title:

Employers Address:

Employers Address:

Mothers Name: Title of Address: (Mrs., Dr., Etc.)

Preferred Phone Number: Preferred Email Address:

Home Address:

Employers Name: Employment Title:

Employers Address:

Employers Address: