PA Supplemental Application

Please send all transcripts directly to CASPA. GRE scores are sent directly to South College (code:1635).

In order to officially apply to the program, please complete your application with CASPA at : http://www.caspaonline.org

You must have a CASPA ID prior to completing this Supplemental Application.

South College
School of Physician Assistant Studies
ATTN: PA ADMISSIONS
400 Goody's Lane
Knoxville, TN 37922

CASPA ID:*
Name:*
Under what other name(s) might documents be received?
Age:*
Date of Birth:*
Place of Birth:*
Race:*
Social Security Number:*
Sex:*

*INFORMATION NEEDED FOR STATISTICAL REPORTING TO THE U.S. DEPT. OF EDUCATION.

Telephone number at which you can be reached between 8:00am and 5:00pm:
-
Home Phone:
-
Cell Phone:
-
E-mail:
Permanent Address:
Temporary Address:
Preferred mailing address:
County and state of legal residence:
Employed by:
Occupation:
Business Phone:
-
Emergency Contact Name:
Relationship:
Emergency Contact Address:
Emergency Contact Phone:
-
Are you a United States Citizen?
In No, indicate Legal Status:
Have you previously applied for admission to South College?
If Yes, when?
School or Program:
How did you learn about the Physician Assistant Program?
EDUCATION
Undergraduate Degree (List all cities, states with dates of schools and universities attended)
#1 College Name:
#1 College Address:
#1 Date of degree (if any):
#1 Dates of attendance:
#2 College Name:
#2 College Address:
#2 Date of degree (if any):
#2 Dates of attendance:
#3 College Name:
#3 College Address:
#3 Date of degree (if any):
#3 Dates of attendance:
Year of graduation:
Major:
Minor:
Graduate Degree (if applicable)
#4 College Name:
#4 College Address:
#4 Date of degree (if any):
#4 Dates of attendance:
#5 College Name:
#5 College Address:
#5 Date of degree (if any):
#5 Dates of attendance:
Year graduate degree earned:
Major (graduate):
Prerequisite Courses
Have you completed all prerequisite courses (as listed on the SCPA website)?
Would you like for a South College Admissions Advisor to contact you about completing outstanding prerequisite courses at South College?
GRE Test Information
Have you taken the GRE?
If Yes, when:
Results - verbal:
Results - quantitative:
Results - Analytical Writing Sample:
If No, when do you plan to do so?
DO YOU WISH TO APPLY FOR FINANCIAL AID?
Medical Military Experience
Branch of military:
Number of years of active duty:
Date of entrance:
Date of discharge:
Type of discharge:
If you are now on active duty, what is the earliest date you would be available to enter the program?
Were/are you a corpsman or medic in the service?
IDC:
18-D:
Will you be attending under the GI Bill?
FERPA RELEASE

South College provides for the confidentiality of student records in accordance with the Family Educational Rights and Privacy Act (FERPA), as amended. I understand that in order to consider my application to the School of Pharmacy, the Office of Admissions will release my student records as necessary to members of the School of Pharmacy Admissions Committee, employees of South College and others who have a need to access my student records in order to process my application for admission.

RELEASE

I hereby release South College and any firm with which South College may contract, from any debts, claims, actions, causes of action, demands, suits, and all liabilities whatsoever both in law and in equity, which may result from participation in any telecast or still photography made by or produced by South College.

In doing so, I hereby grant South College the right to use my name, photograph, likeness, or voice in any production connected with the College.

 I hereby represent and warrant that I am of full age and have every right to contract in my own name in the above regard. I further state that I have read the above authorization and release prior to its execution and that I am fully familiar with the contents thereof.

I certify that all statements made in this supplemental application are complete and true and understand that every student enrolling at South College agrees to abide by all policies and regulations of the College that may be found in the Student Handbook or in the College Catalog or other official publication. I understand and agree that any misrepresentation of facts on this supplemental application is just cause for refusal of admission or dismissal from South College.

As acceptance of this registration, please type your full name below.

Applicant Signature:*

By entering your name, the last four digits of your social security number, and submitting the document, you electronically agree and confirm your understanding of the items, as outlined, in the above document.

Last four of social:*
Word Verification: