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Des Moines University College of Osteopathic Medicine

Special Acceptance Application

Des Moines University, 3200 Grand Avenue, Des Moines, Iowa 50312    www.dmu.edu

 
Title  Last Name First Name

Middle Initial     Preferred Name Maiden Name

Social Security #    (ex: 123-45-6789) 
 
Preferred Mailing Address 

No. & Street City State  Zip   

Home/Evening Phone     Business/Day Phone 

Cell Number      E-mail Address   
Permanent Mailing Address 

No. & Street City State  Zip   

Year you plan to enter Des Moines University: 

Current Undergraduate Institution Attending: 

Will you have a Bachelor's degree by the date you enter Des Moines University?  Yes  No

If "No" above, will your undergraduate school award the degree after the 1st year of medical school?  Yes  No
Briefly list your medically related experience. This can be paid employment, volunteer work or both. List current experience first.
Type of Work/Employer/Agency    Hours Per Week  Dates-From/To

How did you learn about the College of Osteopathic Medicine at Des Moines University? 
(check all that apply) 
AACOMAS  College advisor  Direct mail  Internet/Website 
Newspaper advertising Radio advertising   Recruiting/College Fair 
Referred by current DMU student,  
Referred by DMU alumnus,   
Other

Advisor Data
Name:
Institution:
Email Address:

Alumni Data

The Alumni Relations Office, in an attempt to foster improved communication with our alumni, requests the following information from those applicants who are related to a graduate of our University.

If applicable, please list a relative who graduated from Des Moines University.

Relative Name:
Address:
Relationship:
Program Graduated From:   Year of Graduation:

If additional relatives have graduated from this school, please list in the additional information comment box below.

Are you interested in conducting research while in medical school? Yes   No
Do you have research experience? Yes   No

Have you ever participated in a Health Explorer's Program? Yes   No
If yes, which post?

Have you ever been convicted of a felony or misdemeanor? Yes   No
If yes, please explain in detail:

Application Fee Payment (Your application will not be reviewed until the $50 application fee is received.) For your convenience, you may pay online.

Name as it appears on credit card:  
Type of credit card:   
Credit card number (no spaces please): 
Your 3 or 4 digit security code number from your card:
  How to find your security code number:
On a Visa or MasterCard, please turn your card over and look in the signature strip. You will find (either the entire 16-digit string of your card number, OR just the last 4 digits), followed by a space, followed by a 3-digit number. That 3-digit number is your security code number. On American Express Cards, the security code number is a 4-digit number that appears above the end of your card numbers.
Expiration date:    


If you have any questions or concerns regarding payment, please call our accounting office at (515) 271-1530.

Checklist

Letters of Recommendation ** One Clinician
Two Science Professors
One Character Reference (non-family member)

Submit all of these to:
Des Moines University
COM Admissions
3200 Grand Avenue
Des Moines, IA 50312-9909
Resume
Personal Statement (no more than one page)
Transcripts sent form all colleges/universities attended

** The letters should be sealed by the writer in an envelope and then given to you to include in your application packet. Please do not send more letters than requested and do not send a recommendation letter from a relative. Reference letters may be verified.

Certification

I certify that all statements in this application are complete and true. If any of my statements are incomplete or false, I understand and acknowledge that my application for admission may be denied for that reason. Further, if the incompleteness or falsity of any of my statements is discovered after my matriculation, I may be subject to discipline up to and including dismissal from the program. For the purpose of determining admission only, I consent to and authorize any educational institution which I have previously attended to release academic and/or disciplinary information to Des Moines University.

Accepted students will be required to complete a criminal background check prior to matriculation. 

Notice regarding clinical education: The clinical years of the Osteopathic Medicine program consist of hospital clerkships, general practice rotations, and elective rotations in primary care and medical specialties.  While some of these clinical experiences are available in the Des Moines area, a number of programs are located outside Iowa.  You should be prepared to travel to other sites for your clinical education.  Married students, married with dependents and single parents should thoroughly understand that the University does not promise or guarantee clerkships and rotations in Des Moines.  We will try to accommodate special needs, but you must be prepared to relocate. By submitting this application, you indicate you understand and agree to this policy. 

As part of building the osteopathic medical family, we may release your name, telephone number and colleges attended to Des Moines University alumni. 

By submitting this application, I am agreeing to this certification.

PLEASE BE SURE to print a copy of this form for your personal records.

Please have your letters of recommendation

sent to the following address:

 

Des Moines University

COM Admissions

3200 Grand Avenue

Des Moines, IA  50312