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| Legal Name |
| Last Name: |
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| Middle: |
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| First Name: |
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| Preferred Name (If different from Legal Name) |
| Last Name: |
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| Middle: |
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| First Name: |
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| Birth Date(Month/Date/Year): |
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| Social Security Number |
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| Permanent Address |
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| Street |
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| City, State, Zip/Postal Code |
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| Country: |
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| Current Address (If Different Above) |
| Street |
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| City, State, Zip/Postal Code |
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| Country |
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| Home Telephone |
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| Mobile Telephone |
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| Email Address |
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| IM Screen Name |
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| Place of Birth: City, State, Country |
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| In Case of Emergency Contact: |
| Name: |
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| Telephone: |
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Have You Ever Been Convicted of a Misdemeanor or Felony?
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If Yes, Please Explain
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| Are you a United States Citizen? |
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Is English Your First Language?
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If No, what is?
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| Non U.S. Citizens Complete The Following: |
| What is Your Current Immigration Status? |
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| Other (Please Specify): |
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| Country of Citizenship |
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Plan of Study
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| Please Specify the Year and Term in which You Wish to Enroll |
Year: Term: |
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Name of Transferring Institution:
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Demographic Information
The following information is requested to comply with federal guidelines. The provision of this information is optional and will not be used in determining admissionor financial assistance. |
| Ethnic Background: |
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| Marital Status: |
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| Are you a Veteran of the Armed Forces?: |
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| Gender: |
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Academic Information
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| High School Last Attended: |
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| City, State: |
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| Graduation Date(Month/Year): |
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| If you are not a high school graduate, when did you complete your GED? (Month/Year GED was taken): |
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| List in chronological order all post-secondary institutions you have attended regardless of length of attendance and even if no work was completed. Include previousattendance at this institution and any correspondence or extension courses taken. Attach an additional sheet of paper, if needed. (Official high school or GED and allcollege or university transcripts must be sent to the Office of Admissions. Failure to list all colleges or universities in which you have been enrolled, regardless of status,may disqualify your application.) |
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Extra-CurricularActivities
Briefly describe your involvement in any extra-curricular activities in which you participated. Please include any scholarships or scholastic honors/awards, etc. received. Maximum 250 Words:
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Personal Statement
State why you are interested in becoming a Doctor of Chiropractic, Licensed Acupuncturist, Massage Therapist, or a Master's Degree Prepared Nurse. Provide any additional significant information i.e., experience in a health care delivery setting. Minimum 300 Words:
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Are you a relative of a Southern California University of Health Sciences graduate?
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If yes, whom (Name and relation to you)?
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Have you ever been dismissed or suspended from any college?
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If yes, please explain when and why?
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Have you previously applied for admission to Southern California University ofHealth Sciences?
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If Yes, When?
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| OPTIONAL INFORMATION |
| Will you be requesting financial assistance from Southern California University of Health Sciences? |
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| Are you interested in learning more about our scholarship opportunities? |
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| How were you first introduced to Southern California University of Health Sciences?
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Please state referring individual(s) name, address and phone number (if known)
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| Method of Payment: |
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| The statements I have made are correct to the best of my knowledge. I understand that any misrepresentation or omission of facts requested on this application iscause for disqualification of the application process or for dismissal from the University. If admitted, I agree to conform to all rules and regulations of Southern California University of Health Sciences |