Philadelphia College of Osteopathic Medicine - Synapsis Yearbook (Philadelphia, PA)

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be unpleasant to those that deserve it. Shadwell

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GRAPHIC CHARTS

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This application must be filed before January 1st of the calendar year of desired matriculation Philadelphia College of Osteopathic Medicine 4150 City Avenue, Phladelphia, Pennsylvania 19131 APPLICATION FOR ADMISSION To be considered by the Faculty Committee on Admissions this application must be completed in its entirety. For Class entering 19742 Unless otherwise indicated herein. please type or print. If admitted at a modem. you will be required to submit two (2) walkt•sized (2W z 3 ' ) prints of a full-fared photograph which has ban especially photo. graphed in a studio. Male sttn dents arc to wear a coat and tie for the photo. Women au• dents are to wear business or strew site for the photo. of this Application Z 14 PERSONAL INFORMATION Name in full •Inet TIATIC DOLT .1•11C ‘AIEC Home Address -ILI Sot E444e4 .- AMO CCCCC T CITY COVAITT Mailing Address S Date of Birth 14 U. S. Citizenship: Yes (A No ( ) Home Phone Number of Other Single ( ) Married (); Divorced ( ) Children (44 dependents Social S«urity Y Give the name and relationship ofall relatives in the Osteopathic Profession: PARk.C.3.1 4S WCLBY .O. ; se); rthnis ifringe ,D. oi; ToSt D. o. Have you previously applied for admission to this college? No Yes ( ). Applied for class to start September HEALTH HISTORY Give a brief statement as to any physical and psychiatric, minor and major illnesses: surgery; physical impairment: Ate AS yet S Wear glasses: No ( ) Yes (X? Height 0 g Weight ep. . .