MEDICAL PROFESSIONS STUDENT INFORMATION SHEET

(students should fill out this form and give it to faculty members from whom

letters of recommendation are requested)

Name: ___________________________________

e-mail address: ___________________________ Local Phone #: _________________

Home Address: _______________________________________________________________

Major: ______________________________ Minor: ____________________________

Class(es) with recommender and semester taken:

__________________________________________________________

__________________________________________________________

Program(s) for which letter(s) is/are requested:

Attach form(s) or addresses to whom letters should be sent.

Date letters are due: __________________________

Autobiographical Information:

Motivation for program (could include basis for interest in career choice) -

Academic qualification (could include cumulative GPA, science/math GPA, honors, scholarships, other relevant information) -

(OVER)

Relevant work experience(s), including time spent at work and how work relates to program to which you are applying -

Relevant extracurricular activities -

Professional goals -

Other information specifically requested on application form(s) -

Other relevant information -