Michigan State University

Optional: Insert Your Picture Here College of Osteopathic Medicine DO- PhD Physician Scientist Training Program Application for Admission This applicant has requested the DO-PhD Program consider him/or her for admission to the DO-PHD Program and has freely supplied the requested information Valid for Admission to the 2014 - 15 Academic Year Last Name, First Name, Middle Name: Date of Birth: Female / Male / / mo day yr Current Mailing Address: City State Zip

Current Telephone Number: Mobile/Cell Telephone Number:

Country of Citizenship: Permanent Resident of the US? Type of Visa:

EMAIL ADDRESS: Applied to AACOMAs/When: Offered Admission to MSUCOM: Y/N when: Will take/or have taken the MCAT Undergraduate GRE Scores (may be required of graduate program) On Date: MCAT Total Score: GPA: Verbal: Quantitative: Analytical Writing: Verbal: Physical Sci: Biological Sci: Writing: Graduate GPA: How did You Find Out About the DO-PhD Program?

For the purposes of this application underline or highlight the program you are interested in: 3987 Neuroscience; 0893 Philosophy/Bioethics; 2831 Epidemiology; 4308 Anthropology. The following programs fall under the Bimolecular Sciences Umbrella Program: 4214 Biochemistry & Molecular Biology; 3964 Cell & Molecular Biology; 3788 Genetics; 4215 Microbiology & Molecular Genetics; ; 4178 Pharmacology & Toxicology; 4189 Physiology. Area of Research Interest/Why & MSU Faculty you are interested in working with:

In addition to this form, include a Curriculum Vitae/ Resume, U nofficial Transcripts & a Statement of Purpose. In the Statement, indicate why you want to pursue the DO-PhD Program. Describe research you have done and what kind of research you would like to do and why). Below list all colleges and universities attended and degrees received or expected: College or University Major Field Degree and Date

List who will be writing letters of recommendation regarding your qualifications for the DO-PhD Program and can attest to your motivation and ability to carry out research. Letters should be sent to Graduate Program Director: at the Neuroscience Program Giltner Hall, 293 Farm Lane, Room 108, East Lansing, MI 48824-1101 or the BioMolecular Sciences Program, Biomedical Physical Sciences Bldg, 567 Wilson Rd, Rm 2240, Michigan State University, East Lansing, MI 48824, or other graduate program at MSU. For the Bioethics or Social Sciences PhD Programs, please contact the DO-PhD Program Office for information on where to send letters. Name Department/Position Institution Phone Date Requested 1. 2. 3. Applicant’s Signature______Date: ______For 2014 admission This form can be accessed at http://com.msu.edu//DO-PhD-Program/Admissions.htm & emailed to [email protected] Or MAIL to: DO-PhD Program, 1129 Farm Lane, Room 341 Food safety & Toxicology Bldg, East Lansing, MI 48824-1631