Personal Data 

CASPA ID                      

Please consider this application for the class entering in: January 2009 January 2010

Gender:    Male Female

Full Name

Name you prefer to be called (nickname, if applicable)

Preferred Phone Number (home, work, school and/or cell)

E-Mail address

Religious Preference (optional)

Have you applied to the Mercer University College of Pharmacy and Health Sciences before? Yes No

If so, when?

How did you first hear of Mercer's College of Pharmacy and Health Sciences?

Who is (was) your pre-professional or academic advisor?

Name

Title/Department

College/University

City, State and Zip Code

Please list other PA programs which you are considering for attendance:

Do you have relatives who are Mercer University graduates? If yes, please list them (include name, relationship, degree and class year).

Have you ever been arrested for, convicted of or accused of any violation of law (include all criminal offenses,
i.e., felonies and misdemeanors, infractions, traffic offenses, and everything else except for parking violations,
regardless of the final disposition.)?

Yes            No

If the answer is YES, give a full explanation here including the final disposition of the case:

Narrative

As part of your CASPA application, you are asked to provide a narrative regarding your your motivation towards becoming a PA. At this time, please describe how participation in Mercer's PA Program will foster your development as a healthcare professional. Please do not reuse your CASPA statement. (Please limit your narrative to 500 words. This field cannot be left blank.)

Optional: Please provide any additional comments or information you would like the Admissions Committee to consider during the review of your application (e.g., causes of any academic difficulty or additional qualifications not already noted). (Please limit this information to 250 words.)

I certify that the information presented in this supplemental application is my own work, factually correct and honestly provided.

By typing your name in this box, we will accept that you acknowledge the above statement.

Mercer University is committed to providing equal educational and employment opportunity to all qualified students, employees, and applicants, without discrimination on the basis of race, color, national or ethnic origin, sex, age or disability, as a matter of University policy and as required by applicable State and Federal laws, such as Title IX and Section 504.  Inquiries concerning this policy may be directed to the Equal Opportunity/Affirmative Action Officer, Diane Baca, Personnel Office, 1885 Edgewood Avenue, Macon, GA  31207, (478) 301-2786.