Intent Form for Students Applying to a Health Professions School

The purpose of this form is for students to notify the Health Professions Advisor that they are either in the process of applying or will be applying to a graduate health professional program during the 2011-2012 academic year.

Please print your name and date below and check the appropriate box.

Full Legal Name:

Date: 05/17/2012

Part One: Please check the appropriate boxes:
	I am submitting an application during 2011-2012 for admission to PHYSICIAN ASSISTANT school.
	I am submitting an application during 2011-2012 for admission to PHARMACY school.
	I am submitting an application during 2011-2012 for admission to PHYSICAL THERAPY school.
	I am submitting an application during 2011-2012 for admission to VETERINARY MEDICAL school.
	I am submitting an application during 2011-2012 to another health professional program.
	In this case, please write in the type of program:
	I am submitting an application during 2012 for admission to DENTAL school.
	I am submitting an application during 2012 for admission to MEDICAL school.

Part Two: Students applying to medical and dental schools are required to have a committee letter of evaluation and must be interviewed by the Health Professions Advisory Committee. A committee letter is optional for students applying to other programs.
	I am notifying the Health Professions Advisory Committee that I will be requesting a committee letter and as required, I will interview with the Health Professions Advisory Committee. I understand that I must complete the other forms on the Health Professions Web Page. Form B contains additional information on this process.

Signature

05/17/2012
Date

Submission of online health professions documents will include the use of an electronic signature which is accepted as the equivalent of a handwritten signature.

This form is due on or before February 13, 2012