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> Thank You
Thank You
Thank you for applying to the Physician Assistant Program. You must complete the Supplemental Application below for your file to be complete.
Name
Last:
First:
Middle:
Mailing Address
Street or PO Box
City
State
Zip
Phone
Work:
Home:
E-mail:
Social Security Number:
Describe the type and lifestyle you hope to have after graduation and where you hope to be in 10 years. (no more than 250 words)
Where did you spend the major portion of your high school years?
Large city (population 500,000 or more)
Suburb of a large city
City of moderate size (population 50,000 - 500,000)
Suburb of moderate sized city
Small city (population 10,000 - 50,000, other than suburb)
Town (population 2,500 - 10,000, other than suburb)
Small town (population less than 2,500)
Rural or unincorporated area
Choose the medical specialty in which you would most like to work:
Anesthesiology
Dermatology
Emergency Medicine
Family Practice
Geriatrics
Internal Medicine
Neurology
Obstetrics and Gynecology
Opthalmology
Orthopedics
Otolaryngology
Pediatrics
Physical Medicine/Rehab
Public Health/Preventive Medicine
Psychiatry
Surgery
Undecided/No Preference
In what setting would you most like to practice after training as a physician assistant?
Large city (population 500,000 or more)
Suburb of a large city
City of moderate size (population 50,000 - 500,000)
Suburb of moderate sized city
Small city (population 10,000 - 50,000, other than suburb)
Town (population 2,500 - 10,000, other than suburb)
Small town (population less than 2,500)
Rural or unincorporated area
Would you be willing to practice in a socio-economically deprived area?
Yes
No
Don't Know
All information given in this application is true to the best of my knowledge. I authorize any schools or colleges I have previously attended to release personal and academic information to the Jefferson College of Health Sciences. I agree, if accepted, to abide by the policies established by the Jefferson College of Health Sciences.
Full Legal Name:
Date:
Email Address:
Jefferson College of
Health Sciences
101 Elm Ave., SE
Roanoke, VA 24013
webmaster@jchs.edu
1-888-985-8483
© 2012 Jefferson College of Health Sciences. All Rights Reserved.
Monday, May 21, 2012
