APPLICATION FOR ADMISSION Master of Public Health Program School of Medicine Department of Epidemiology and Preventive Medicine Mail completed application to: 660 W. Redwood St., Room 134 • Baltimore, Maryland 21201-1596 • $75 Application Fee Required • Make checks payable to the University of Maryland, Baltimore Please Type or Print Neatly
Social Security Number: ________ - ______ - ________ Last/Family Name: ______________________________
Prefix (circle one):
Mr.
First Name: _________________________
Mrs.
Ms.
Dr.
Middle: _______ Suffix:_______
Previous Last Name (if any): _________________________________________________________ Permanent Address: _______________________________________________________________ Street: ___________________________________________________________________________ City:_________________________________________ State:_____________
Apt.#:____________________________________
Zip/Postal Code:_______________
Country:_________________
Mailing Address (if different from above) Street: _______________________________________________________________________ City:____________________________________ State:______________ Home Phone: (____) _______ - _______________
Apt.#:_______________________________
Zip/Postal Code:_______________
Country:_________________
Work Phone: (____) _______ - _______________
Email Address: __________________________________________________
Gender*: Male
Female
Date of Birth*: (Mo/Day/Year). __________________
Are you a United States Citizen? Yes No
If No, Country of Citizenship? ______________________________________________________
Country of Permanent Residence: ________________________________________ Alien Registration No.: _________________________________ Current or Intended US Immigration Status:________________________________ Native Language:______________________________________ Race/Ethnicity*: Asian or Pacific Islander (US Citizen or Permanent Resident) Black/Non- Hispanic (US Citizen or Permanent Resident) Caucasian (US Citizen or Permanent Resident)
Hispanic (US Citizen or Permanent Resident)
Native American (US Citizen or Permanent Resident)
International (Non-US Citizen)
Other. Please specify: _______________________________
*for statistical purposes only
Desired Degree
MPH
Full-time or
Part- time
Non-Degree (requires application, resume, and transcript)
Desired Entry Term (Check One Only):
Fall
Spring
Summer
of Year:_____________
Desired MPH Concentration (Check One): Epidemiology Community and Population Health Undecided
Are you applying for a UMB Dual Degree? Yes
No If No, skip to Test Score Section
Students applying to or enrolled in one of the following UMB professional degree programs may apply for dual-degree admission: JD, MD, MSW, PharmD, and MS, Nursing. (Admission to the MPH program is contingent upon the student’s acceptance into the professional school.) Current student New applicant Please indicate primary UMB Professional School ______________________ and degree _____________________
Test Score Information (include an official copy of your scores with your application) GRE Verbal: ____________ GRE Quantitative: __________ GRE Analytical: ___________ Date Taken: _______________
MCAT Scores:____________ Date Taken:______________
LSAT Scores:____________ Date Taken:______________
PCAT:__________________ Date Taken:______________
VCAT Scores:_____________ Date Taken:______________
DAT Scores:_____________ Date Taken:______________
GMAT Scores:___________ Date Taken:______________
Applicants whose native language or language of the home is not English must take the Test of English as a Foreign Language (TOEFL) or the International English Language Testing System (IELTS). TOEFL or IELTS (include an official copy of your scores with your application) Test Name: ____________________________ Total Score: ____________________________ Date Taken: ____________________________ Prior College Information: Please list all colleges or universities attended beginning with the current or most recent Name
Location (Country/State)
Dates Attended
Degree
Date Awarded/ Expected
GPA
Professional/Academic References: Please list the names and addresses of three individuals whom you have asked to submit letters of recommendation Name Address Position
I certify that the information on this application is complete and correct. I agree to abide by the rules and regulations of the University of Maryland, Baltimore if admitted. Signed: ___________________________________________________________________ Date: ________________________________________
Emergency Contact Information (optional): Please enter name, address, telephone number, and relationship to an individual who may be contacted on your behalf in the event of an emergency:
______________________________________________________________________________________________________________________
revised July 2008
STATEMENT OF ACADEMIC GOALS AND RESEARCH INTERESTS Master of Public Health Program School of Medicine Department of Epidemiology and Preventive Medicine
Social Security Number
Last Name:___________________________________First Name:_______________________________ Middle:________________ Please discuss concisely, on this page, your academic objectives pertaining to the MPH and the concentration in which you plan to study. Include contemplated projects and professional career goals. Please include a description of relevant work experience as appropriate. Please type. Continue on the back if necessary.
PLEASE INCLUDE THIS STATEMENT WITH YOUR APPLICATION