1. Last Name:
2. First Name:
3. Middle Name:
4. Address 1:
5. Address 2:
6. City:
7. State -Select- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
8. Zip Code:
9. Social Security Number: Providing your social security number is voluntary. The number is used soley for record keeping and identification purposes.
10. Daytime Phone:
11. Evening Phone:
12. Email:
13. Current State of Legal Residence: -Select- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Applicants are required to submit GRE scores with their application. You should request that the testing agency send an official report of your scores to the Marietta College PA Program, and also report your scores below for review.

Please respond to the following questions limiting your response to 800 words or less.

1. 1. Describe three (3) current issues and/or concerns regarding the current delivery of health care in the United States, and how as a physician assistant you can help benefit your patients and your profession:
2. 2. Describe your practice in 10 years:
3. 3. Describe your learning style and how you will use this style to acquire all of the information presented to you during your PA education:
4. 4. Additional information you believe would be pertinent to the admission process:

The mission of the Marietta College PA Program is to help meet the need for qualified health care providers. A requirement for practice as a PA is certification, licensure or registration with the appropriate state regulatory agency. These agencies require applicants to respond to questions about past professional and criminal activities. Application to the Marietta College PA Program requires you to complete the following items, similar to those required for certification as a PA in Ohio. Please answer each of the following questions by checking either YES or NO.

1. 1. 1. Have you ever had a professional license, certification or registration, in Ohio or any other state, denied, canceled, limited, suspended or revoked?
      
      1. Yes
      2. No 
   2. 2. Have proceedings ever been instituted against you for cancellation, limitation, suspension, or revocation of your professional license, certification or registration by a state regulatory authority?
      
      1. Yes
      2. No  
   3. 3. Have you ever been convicted, or is there now pending, any criminal prosecution against you which would constitute a felony, involve your professional practice, or involve moral turpitude?
      
      1. Yes
      2. No  
   4. 4. Have you ever appeared, or been requested to appear, before any licensure board concerning any violation by you or any law, rule or regulation of any state, district, territory or province in the United States or Canada?
      
      1. Yes
      2. No
   5. 5. Have you ever had your hospital privilege revoked, reduced or otherwise restricted?
      
      1. Yes
      2. No
   6. 6. Have you ever been subject to proceedings by a professional society or association to revoke, reduce or restrict membership?
      
      1. Yes
      2. No
   7. 7. Have you ever been notified by a medical facility, professional society or association, or any licensing agency or regulatory authority of a formal complaint against you?
      
      1. Yes
      2. No
   8. 8. Is there any other information, not noted elsewhere, that would adversely affect your ability to function as a physician assistant?
      
      1. Yes
      2. No

If you have answered YES to any of the above questions you must furnish full details and mail that information to us at paprog@marietta.edu. Falsification or knowingly providing inaccurate or incomplete information to answer and explain your answers to these questions, will be considered grounds for immediate dismissal from the Marietta College PA Program. Background checks are performed on all students accepted for admission to the Marietta College Physician Assistant Program.