UGME Division of Medical Education
Educational
Support Services

Application

All required fields are marked with a red asterisk (*)

Student's Personal Information
1. Full Legal Name Last*
 First*
 Middle Initial
2. Address at School Street Address*
  City*
 State*
 Zip*
3. Permanent Home Address Street Address*
  City*
 State*
 Zip*
4. Email Address*
5. Phone Local*
 Permanent*
 Cell
6. Date of Birth*
7. Birthplace (City, State, Country)*
8. A California Resident?*
9.Number of years as a California Resident
10. If not a California resident, give state of residency
11. United States Citizen?*

12. Permanent Resident?

Alien Registration
Number
 Date/Year of Permanent Resident Status
13. Marital Status Status*
 Number of children*
Other dependents? (Please specify)


Parents' Biographical Information
14. Father Name*
  If deceased, when?
15. Mother Name*
  If deceased, when?
16. Emergency Contact Name*
  Contact number*
17. List highest level of
education completed by		 Father*
Mother*


Academic Information
Please list chronologically all colleges/universities attended:
Name* Location* Begin*
MM/YY		 End*
MM/YY		 Degree* Major* Graduation*
MM/YY
  Overall Undergraduate GPA*
 Undergraduate Non-Science GPA*
 Undergraduate Science GPA*
Please indicate if you have been admitted to UCSD SOM or are on the waiting list? *

How did you hear of this course?
Would you like to be supplied with lists of housing rentals nearby?

Please review the form before submitting below. Once submitted, changes cannot be made online.


Signature
Signature*
In completing this field entitled "signature" on this admission form, I testify that I have signature authority to sign this form. Furthermore, this document, signed with a digital signature, shall be as legally binding as a document signed with a handwritten signature, an affixed thumb-print or any other mark; and a digital signature created shall be deemed to be a legally binding signature.

       

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