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?

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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