Download application for admission to: for office use only

APPLICATION FOR ADMISSION TO:
FOR OFFICE USE ONLY
MSOT Program
Florida A&M University
Division of Occupational Therapy
Ware-Rhaney Building, Room 318
Tallahassee, Florida 32307
Date Received: ______________
FAMU Student:
First Time Applying:
YES
YES
NO
NO
FLORIDA A&M UNIVERSITY
Division of Occupational Therapy
APPLICATION FOR ADMISSION
MASTER OF SCIENCE IN OCCUPATIONAL THERAPY
Please TYPE and return this application to the Admissions Coordinator, Florida A&M
University, Division of Occupational Therapy, Tallahassee, Florida 32307-3200
Have you previously applied for admission to the Florida A&M MSOT Program?
Yes________
No _________
BIOGRAPHICAL DATA
Name: Last: ___________________ First: __________________ Middle: ______________ Maiden: ___________
Social Security Number (Last Four Digits): _____ _____ _____ ______
Ethnic Background: Federal law requires the University to report the ethnicity of all U.S. citizens and
Aliens in the following 5 categories: Please CIRCLE ONE:
Black, Non-Hispanic
Hispanic
Asian or Pacific Islander
American Indian or Alaskan Native
Caucasian
Nation of Citizenship: _________________________ Country of Birth: ___________________________
Give alien registration card number if you are NOT a citizen but have permanent residency status: _____________________
Are you a resident of Florida? Yes_____________ How Long? __________________
No _______________
PRESENT ADDRESS:
City:________________________________ State: ____________________ County: __________________ Zip:___________
Email:__________________________________________
Telephone: ____________________________________________
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Place of Employment: _____________________________________
Phone Number: _________________________________
PERMANENT ADDRESS:
City: ________________________________ State: ____________________ County: __________________ Zip: ___________
Indicate preference of receipt of your mail:
Present Address________________
Permanent Address ________________
EDUCATIONAL BACKGROUND
List all undergraduate colleges, universities, or professional schools, beginning with the most
current or most recently attended institution. Please provide an OFFICIAL copy of your
transcript(s). If you have attended institution(s) other than FAMU, please provide an
OFFICIAL copy of course descriptions (university or college catalog) as well as an OFFICIAL
copy of your transcript.
Institution
Address
Major
Attendance
To
From
Anticipated Date of Enrollment in FAMU MSOT Program:
Summer ______ (Year) 20___
Fall____ (Year) 20___
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Degree or
Certification Date
References: List the names of the three persons to whom you have sent recommendation
forms and their relationship to you. (PLEASE print clearly)
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
List any volunteer and/or observation hours. You MUST submit letters from
registered/licensed Occupational Therapists, on their company letterhead, to substantiate
hours (30) of observation completed:
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
5. __________________________________________________________________
List any organizations or community programs in which you have participated. If they
could be resources for student fieldwork and / or research projects, please so indicate.
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
4. __________________________________________________________________
5. __________________________________________________________________
GRE/TOEFL Exams Taken:
GRE: Yes ______ No ______ Date: ___________
TOEFL: Yes ______ No_____ Date ________
Did you request that your official scores be sent to the FAMU Graduate School ?
Yes ______ No _______
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The following faculty provided me with information/or advisement in regard to the
FAMU MSOT Program:
1. __________________________________________________________________
2. __________________________________________________________________
Have you ever been placed on probation or dismissed from an Occupational Therapy
Program? Yes _______ No _______
If Yes, please explain _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever been convicted of a criminal offense? Yes _____ No _____
If yes, please be conscious that an official background check is required of all students
before they can begin their fieldwork experiences. Also, you will need to submit
appropriate information to the National Board for Certification of Occupational Therapy
(NBCOT) for an “Early Determination Review”. Per the NBCOT: An individual who is
considering entering an educational program or has already entered an education
program can have his or her background reviewed prior to actually applying for the
exam by requesting an early determination review. The fee for this review is $100.00. In
this “early determination review” process, the NBCOT may give early or prior approval
to take the certification exam, as it pertains to good moral character, provided that the
information reviewed is not found to be in violation of any of the principles of the Code of
Conduct.
This review is intended to provide you with valuable information regarding your potential
to practice, to acquire licensure and national certification upon graduation and is not
intended as a punitive or discrimination measure for applicants having a criminal
conviction. Results of an “Early Determination” NBCOT review need not be submitted
to the program. If results indicate that certification or licensure may be a problem the
applicant may be advised to withdraw from the admission process.
NOTE: If you have additional questions or would like additional information you may
contact the Credentialing Services at NBCOT, located at 800 Frederick Avenue, Suite
200, Gaithersburg, Maryland, 20877; phone 301-990-7979 or contact
[email protected].
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EMPLOYMENT HISTORY
Complete the following employment history form. Include time spent doing volunteer work.
(Add additional pages if needed)
1. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________
Address: City: State: Zip: ______________________________________________________________________
Title: ________________________________________________________________________________________
Overview of Duties: ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Hours of Volunteer Work: _____________________________________________________________________
2. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________
Address: City: State: Zip: ______________________________________________________________________
Title: ________________________________________________________________________________________
Overview of Duties: ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Hours of Volunteer Work: _____________________________________________________________________
3. Employer: _____________________________________ Date:_______________ Hrs./Wk:_________________
Address: City: State: Zip: ______________________________________________________________________
Title: ________________________________________________________________________________________
Overview of Duties: ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Hours of Volunteer Work: _____________________________________________________________________
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ADMISSIONS ESSAY
Attach a TYPED, double-spaced, admissions essay. The purpose of the essay is to
evaluate your understanding of and commitment to the profession, in addition to your
thinking and writing ability. In this essay you should write about the following:
1. Your perceptions about the impact of occupational therapy on the health and
well being of individuals and/or groups.
2. Why and how occupational therapy will meet your personal and professional
goals.
3. Your participation in a meaningful occupation that has influenced your own
personal and/or professional growth.
Note: SIGN AND DATE the bottom of the essay.
PRE-REQUSITE COURSES:
The following pre-requisite courses must have been taken within the past 10 years and the
overall GPA for them must be 3.0 or better. Indicate where and when taken, and the
grades you received.
Course Title
Credits
Taken at
Date(mm/dd/yy) Grade
Human Growth and Development
3
Intro to Anthropology or Sociology
3
Intro to Psychology
3
Abnormal Psychology
3
General Biology with Lab
4
Chemistry (“Fundamentals” or higher) 3
College Physics I
3
College Physics Lab
1
Anatomy and Physiology I
3
Anatomy and Physiology I Lab
1
Anatomy and Physiology II
3
Anatomy and Physiology II Lab
1
Introduction to Statistics
3
Introduction to Research
3________________________________________
Total required pre-requisite credits
37
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PLEDGE BEFORE A NOTARY PUBLIC
“I certify that the information provided on this application and attached documents herein
are true and accurate to the best of my knowledge. I understand that withholding
information or giving misleading information, omissions or falsifications may result in a
withdrawal of an offer to accept me. I understand that it is my responsibility to ensure
that application materials are received by the identified deadline date. I further
understand that I must request and provide official transcripts from all previous colleges
and universities attended before acceptance into the Florida A&M University MSOT
program.”
______________________________________
Signature of Applicant
__________________
Date
Your NOTARIZED signature is REQUIRED
Sworn to and Subscribed before me this _________________ Day of _________, 20____
_______________________________________
Notary Public
My Commission Expires ___________________
SEAL
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