ST.

LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

DATE OF APPLICATION: _______________________ __ M.D. __Ph.D. __MSc. __MSc Nursing __MPH

This is my first a follow-up a transfer application Externship

For office use only

Accepted

For matriculation in

MEDICINE: Basic Sciences Clinical Sciences _______ year _________ specialty Medical Externship: Year of Graduation _____

Online Program Joint MD-Ph.D. Program MBBS-MD conversion or Ph.D. Program

Rejected

_________ specialty

MSc Program Ph.D. Program: Please circle appropriately: Anatomy, Physiology, Neuroscience, Biostatistics, Medical Sciences, Molecular Biology, Occupational Health, Public Health. MSc Nursing Ph.D. Nursing LOCATION (circle one): Liberia, or Online,USA (Clinical/Dual programs only). Consideration for trimester : Spring 20____ Fall 20____ Winter 20____

!0+2 Exams GRE USMLE-1 CSA MCAT Score USMLE-2 OTHERS

Application Fee ____ $75.00 First Name Matriculation Fee ____ $600.00 Middle Name(s) Visa Status Country Expiration Date (provide copy)

Last Name Social Security Number Drivers Licensee Number Sex State or Province

GENERAL INFORMATION

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

List all Colleges/Universities Attended in Order. Please Include Addresses

Dates of Attendance

Major or Fields of Concentration

Degree & Date awarded, if applicable (Please send a copy of diploma)

ACADEMIC RECORD (Please list additional colleges and universities on separate pages) Date Taken Scores: Verbal Physical Science Writing Biological Science

MEDICAL COLLEGE ADMISSIONS TEST (Recommended, optional). Please submit copy of test score. Other Test Scores (please list date and scores). Please submit copy of results.

USMLE -1

USMLE-2

CSA

GRE

MARITAL STATUS:

SINGLE

MARRIED

DIVORCED

NUMBER OF DEPENDENTS: __________ NAME OF SPOUSE: __________________ OCCUPATION: __________________ Dependents Names & ages: _________________________________________________________ FAMILY INFORMATION ________________________________________________________________________________ Fathers Name: __________________ Occupation: __________________ Mothers Name: __________________ Occupation: __________________

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Do you have any physical disabilities or history of mental illness? If yes, please explain on a separate sheet.

yes

no

Do you have any particular medical conditions that may require special attention during medical school? yes no If yes, please explain on a separate sheet. Have you ever been dismissed from any academic institution? If yes, please explain on a separate sheet. Have you ever been charged with or convicted of a felony? If yes, please explain on a separate sheet. yes no

yes

no

Have you previously attended an American or other (foreign) Medical School? If yes, please list institutions below with dates of attendance. PERSONAL INFORMATION

yes

no

How do you plan to finance your medical education? Please indicate the percent of support you anticipate in each category. ____ % Loans ____ % Family/Parental Support ____ % Personal Savings ____ % Other Sources Please choose a payment plan from the options at the back of this application. ____ Plan A ____ Plan B ____ Plan C ____ Please indicate the number of family members and/or other dependents who might join you. __________________________________________________________________________________ How did you find out about St. Luke School of Medicine? Please list your employment history beginning with your current job. Job & Title Name & Address of Employment List clinical experience in hospitals, health centers or physicians offices. List Interests, Hobbies, other pursuits, or travel outside of your home country. Dates

EMPLOYMENT HISTORY, MEDICAL EXPERIENCE, ACTIVITIES, HOBBIES, TRAVEL EXPERIENCE

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Please write your personal essay. Why do you want to pursue this professional goal? Please tell the Admissions Committee why you would be an asset to St. Luke School of Medicine. Also, include what you want to do after you become a Medical Doctor, or after completing your graduate education. Please attach four color passport-sized facial photographs of yourself on to this page. Please tell the Admissions Committee what your medical and humanitarian goals are. Include your professional ambitions.

Please place an up-to-date photograph of yourself here

I certify the information submitted on this application is true, correct, and accurate to the best of my knowledge and no information was withheld. Signature of Applicant Date

______________________________

_____________________

Note: Any misleading or false information supplied by an applicant will be grounds for withdrawal of acceptance and may constitute grounds for dismissal or even revocation of diploma (if granted). Please include your application fee of $75.00 (USD).
Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu Page 4 of 11

ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

FOR ALL APPLICANTS

Please designate which of the recommended St. Luke School of Medicine prerequisite courses you have completed at any accredited college or university. These courses must be verified by transcript and college, university, or medical school catalog, bulletin, or prospectus. THESE ARE UNIVERSITY LEVEL COURSES.
Course English Composition Grade Course English Literature Arts, Music, or Art or Music Appreciation Grade

Computer Science

Optional Courses
Course Microbiology Grade Course Parasitology *Other Advanced Courses (please name courses) Grade

*Advanced Mathematics (please name courses)

Advanced courses are defined as level 200 or above (3rd or 4th year undergraduate, or graduate courses.

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

FOR TRANSFER STUDENTS ONLY Please designate which of St. Luke School of Medicine basic science courses you have completed at another World Health Organization recognized medical school. This must be verified by transcript and medical school catalog, bulletin, or prospectus.
SEMESTER 1 Human Anatomy Hours 600 160 40 SEMESTER 2 Medical Biochemistry PH 2 - Public Health Policy Hours 620 160 40

Nutrition SEMESTER 3 Systemic Pathology 1 Hours 620 120 40 SEMESTER 4 Systemic Pathology 2 Hours 600 140

PH 3 - Community Medicine

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

FOR TRANSFER STUDENTS ONLY Please identify which of St. Luke School of Medicine clinical rotations (Clerkships) you have completed at another World Health Organization recognized medical school. This must be verified by transcript and medical school catalog, bulletin, or prospectus.

CLINICAL SCIENCE SCHEDULE CORE Radiology ________ Liberia 68 Weeks 04 weeks

___ _ ___ _ Weeks Total 80 National Service ________ 08 weeks

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Dear Student Applicant If you have not already done so, please send the following documents: Pay your application fee of $75.00 USD and your one-time Matriculation fee of $600.00 USD. Your tuition is due four weeks before your start your courses, or immediately if you want to immigrate as a student to the USA. Original transcripts from each college and university attended. These transcripts must be sent from each college and university attended. You have three months from date of acceptance, above, for receipt of transcripts at the SLSOM office. A Copy of your Driver's license or other local, state, provincial, or national ID card. Copy of Social Security Card, for US or Canadian citizens, or United Kingdom equivalent. A complete cover-to-cover copy of your passport. Four (4) passport photographs, in color. A police report from the city, state, province, or country of your residence and/or citizenship. A complete physical examination report. Three (3) letters of recommendation from verifiable, reputable individuals.

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Flexible Tuition Payment Plans

PLAN A - CASH ADVANCED PAYMENT Students must pay $75.00 application fee and $600.00 matriculation fee to start the program. Students that pay full tuition for the total program will receive a 15% discount. NO REFUNDS NO EXCEPTIONS PLAN B - PAY AS YOU GO Students must pay $75.00 application fee and $600.00 matriculation fee to start the program. Students may pay $3500.00 (money order/cashier's check) every 4 months. $1750,00 every 2 months or $875.00 per month. Students with Plan B will be eligible for certification for licensure exams, and will be able to request official transcripts as long as the student is current with payments as agreed. Diplomas will be sent after all financial obligations have been met. PLAN C - FAMILY PLAN DISCOUNT To be eligible for this discount, there must be two or more members of the same nuclear family Each family member must pay $75.00 application fee and $600.00 matriculation fee to start the program. Family members will receive a 15% discount on fully paid tuition and or payment plans A or B.

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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ST. LUKE SCHOOL OF MEDICINE

DOCTOR OF MEDICINE or GRADUATE PROGRAM APPLICATION __________________________________________
USA Information Office: 8516 11th Avenue, 2nd Floor, Inglewood, CA 90305

Refund Policy
St. Luke University adheres to a fair and equitable refund policy. This policy applies to students who withdraw from the School of Medicine and/or other allied health programs given by the University. New applicants to St. Luke School University requesting withdrawal within three days of payment of the matriculation fee or tuition shall receive a full refund of all monies received with the exception of the application and matriculation fee. All students must send a certified, written withdrawal letter, submitted to the Chief Financial Officer. Refunds are disbursed within 30 days of the formal withdrawal date according to the schedule below: Prior to the first day of class During the first week of class 100% 80% $50.00

Refund Processing fee ADVANCE PAYMENTS ARE DISCOUNTED 15%. THEREFORE, THERE ARE NO REFUNDS FOR ADVANCED PAYMENTS Students in clinical rotations are also required to submit a certified, written withdrawal letter, submitted to the Academic Dean. Tuition is refunded according to the above schedule less any nonrefundable hospital charges. Any questions regarding the St. Luke University refund policy please call the SLSOM Financial Officer at (714) 265-7736.

Phone: (323) 565-2725, Fax: (323) 565-2724, E-Fax: 323-372-3757 Website: http://www.stluke.edu, E-mail: admissions@stluke.edu

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