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University of Hawai‘i at Ma noaJohn A. Burns School of Medicine
651 Ilalo Street, MEB • Honolulu, HI 96813Telephone: (808) 692-1030 • Fax: (808) 692-1254
‘Imi Ho‘ola Post-Baccalaureate Program
PERSONAL
INFORMATI
ON
NAME:
_________________________________________________
Current Mailing Address:
_________________________________________________
_________________________________________________
Permanent Mailing Address: (if different from current mailing address)
_________________________________________________
_________________________________________________
Telephone: ______________________________________
E-mail address: __________________________________
Legal Residence:
_________________________________________________
LAST FIRST M.I.
STATE COUNTRY
AMCAS ID #: _______________________________
Date of Birth: ______ / ______ /______ Age: ____
Gender Male Female
Other ________________________________________
Marital Status:
Single Married Divorced
Other ________________________________________
Birthplace:
____________________________________________
Ethnicity (list all):
____________________________________________
____________________________________________
____________________________________________
____________________________________________
STATE COUNTRY
2020-2021 Application
Citizenship: ________________________________
Visa Status (if not U.S. citizen): ________________
Is English your first language? (primary language spoken in the home)?
YES NO
Geographical area you spent the majority of your life from birth to age 18 (street address required): Choose one location only.
______________________________________________________
______________________________________________________
STREET ADDRESS
CITY/TOWN STATE ZIP CODE COUNTRY
See Application Booklet for Printing Instructions.
Nam
e: ____________________________________________________
Late or incomplete applications will not be considered.1
Name: ____________________________________________________
F A M I L Y
B A C K G R O U N D
* List current or most recent occupation. If retired or deceased, list the last occupation held.
Paternal Grandfather Paternal Grandmother
Maternal Grandfather Maternal Grandmother
Name:
Current Address:
Telephone:
Marital Status:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
Father Mother
EDUCATION Number Years of schooling: (i.e., 16 years = 12 + 4 college)Highest degree attained: Name of school: (ie: High School, University)
Occupation:*
Duties/Responsibilities:
EDUCATION Number Years of schooling: (i.e., 16 years = 12 + 4 college)Highest degree attained: Name of school: (ie: High School, University)
Occupation:*
Duties/Responsibilities:
EDUCATION Number Years of schooling: (i.e., 16 years = 12 + 4 college)Highest degree attained: Name of school: (ie: High School, University)
Occupation:*
Duties/Responsibilities:
2
Name: ____________________________________________________
E C O N O M I
C
B A C K G R O U N D
Combined Annual Income of Parent(s):(Based on 2018 U.S. income tax return. Please complete whether or not you are self-supporting.)
$28,760 and under $28,761 - $38,920 $38,921 - $49,080 $49,081 - $59,240 $59,241 - $69,400 $69,401 - $79,560 $79,561 - $89,720 $89,721 - $99,880 $99,881 or more
How many people are claimed on 2018 U.S. income taxreturn including yourself (if applicable) and your parent(s)/guardian(s)?_________________________________________________List their relationship to you and their ages. Include yourself if applicable:RELATIONSHIP AGE
Annual Income of Applicant (Combined with Spouse if Applicable):(Based on 2018 U.S. income tax return. Do not complete if you are claimed as a dependent by your parents.)
$28,760 and under $28,761 - $38,920 $38,921 - $49,080 $49,081 - $59,240 $59,241 - $69,400 $69,401 - $79,560 $79,561 - $89,720 $89,721 - $99,880 $99,881 or more
How many people are claimed on 2018 U.S. income taxreturn including you and your spouse?_________________________________________________List their relationship to you and their ages:
RELATIONSHIP AGE
___________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________SPOUSE’S OCCUPATION: _______________________________
Is the combined annual income of your parent(s) or guardian(s) for year 2018 U.S. income tax return below $90,200 (Hawai‘i median income based on U.S. Census Bureau for 4-Person Family)?
YES NO
Have you or members of your immediate family ever used Federal or State assistance programs (e.g., foodstamps, free lunch, welfare)?
YES NO If yes, list year(s) received assistance:
Did you have paid employment prior to age 18?
YES NO
If yes, were you required to contribute to the overall family income (as opposed to working primarily for own discretionary spending)?
YES NO
Have you used need-based scholarship(s) or loan(s) to fund your undergraduate or graduate education?
YES NO
3
Name: ____________________________________________________
E DUCATI
ONAL
B A C K G R O U N D
High School where you received your diploma: Public Charter Private Home School Other
________________________________________________________________________________________________________________
High School attended, if different from graduated from: Public Charter Private Home School Other
________________________________________________________________________________________________________________
Were your science courses/laboratory experiences sufficient to prepare you for college? YES NO
Did you utilize science courses/lab experiences to prepare you for college? YES NO
Did your high school provide you with sufficient counseling that encouraged you to pursue a bachelor’s degree? YES NO
Undergraduate, Graduate and Professional Schools Attended: All undergraduate colleges attended (list most recent first):
___________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ ______
INSTITUTION CITY/STATE DATES ATTENDED MAJOR DEGREE EXPECTED
DATEGRANTED/
Graduate or Professional School(s) attended:
___________________________ ____________ _____________ ____________ _______ _________________________________ ____________ _____________ ____________ _______ ______
Have you ever been placed on probation, suspension, or dismissal by a college or university? YES NO
If yes, provide complete details below, including date(s) of action(s). Attach additional sheet if necessary.________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Do you have a physician or healthcare role model/mentor? YES NO
Did you have a support system while attending college? YES NO
HIGH SCHOOL NAME
HIGH SCHOOL NAME
CITY
CITY
STATE
STATE
YEAR GRADUATED
YEAR(S) ATTENDED
Did you apply to the ‘Imi Ho‘ola Program previously? YES NO If yes, what year(s)?
Did you apply to JABSOM previously? YES NO If yes, what year(s)?
INSTITUTION CITY/STATE DATES ATTENDED MAJOR DEGREE EXPECTED
DATEGRANTED/
4
Name: ____________________________________________________
SOCIAL
BACKGROUND
List Health Career Opportunity Programs (HCOP) and other disadvantaged programs you have participated in:
Organization Name: _____________________________________ Dates: __________________________________________City/State/Country: ______________________________________________________________________________________Experience Name: ______________________________________________________________________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: _____________________________________ Dates: __________________________________________City/State/Country: ______________________________________________________________________________________Experience Name: ______________________________________________________________________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
List College Honors/Awards:
__________________________ _________________________ _______________________________
__________________________ _________________________ _______________________________
__________________________ _________________________ _______________________________
NAME OF AWARD DATE RECEIVED DESCRIPTION
List Research Experiences:
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
5
E X T R A C U R R I
C U L A R
A. Extracurricular College Activities (list most recent first):
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
B. Volunteer Health Experience, Public Service, or Community Activities (list most recent first):
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
C. Employment (list most recent first):
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
Organization Name: ______________________________________________ From: Month: ____________ Year: _________City/State/Country: ______________________________________________ To: Month: ______________ Year: _________Experience Name: ______________________________________________ Total Hours: ____________________________Experience Description: ______________________________________________________________________________________
______________________________________________________________________________________
6
Name: ____________________________________________________
A. Describe why you want to pursue a career in medicine. What key experiences have influenced this decision?
P E R S O N A L
S T A T E M E N T
3000 character maximum, single space 12 pt font (spaces are counted as characters)
7
Name: ____________________________________________________
B. Describe any family or personal circumstances (e.g. hardships) that will be useful in reviewing your application.
P E R S O N A L
S T A T E M E N T
1500 character maximum per essay, single space 12 pt font (spaces are counted as characters)
C. Describe how you have been able to overcome any personal hardship or adversity that you have faced.
8
Name: ____________________________________________________
D. 1) Describe your past and current demonstrated commitment to serve in Hawai‘i and/or the Pacific Region.
P E R S O N A L
S T A T E M E N T
Please answer each question separately. 750 character maximum per essay, single space, 12 pt font (spaces are counted as characters)
2) What is your most significant experience in the areas of community service, volunteer and/or leadership and why did you choose this experience?
3) How do you envision yourself serving in areas of need as a future physician?
4) Following your residency training, what types of patients will you serve and where do you wish to practice?
9
Name: ____________________________________________________
Date of most recent MCAT: ____________________
List Medical Schools that you are currently applying to:
______________________________________________________ ___________________________________________________
______________________________________________________ ___________________________________________________
______________________________________________________ ___________________________________________________
______________________________________________________ ___________________________________________________
Recommender: _______________________________________ Title: ________________________________________________
Recommender: _______________________________________ Title: ________________________________________________
MEDICAL SCHOOL MEDICAL SCHOOL
Two letters of recommendation are required. At least one of the letters should be from a professor or advisor that can attest to applicant’s academic ability. (Maximum two letters of recommendations will be accepted.)
How did you hear about the ‘Imi Ho‘ola Program?______________________________________________________________
CertificationI certify that the information submitted in this application is complete and correct to the best of my knowledge. I understandthat any misrepresentation, falsification, or failure to supply required information in connection with this application may resultin the rejection of my application. I agree to notify the ‘Imi Ho‘ōla Post-Baccalaureate Program of any changes thatarise during the application process.
_________________________________________________________________ _________________________________________SIGNATURE DATE
* Please mail the original form directly to the ‘Imi Ho‘ola Post-Baccalaureate Program by the postmark deadline ofNovember 1, 2019 and keep a copy for your personal records.
Late or incomplete applications will not be considered.
John A. Burns School of Medicine
10
APPLI
CANT
NOTES
APPLI
CANT
NOTES