PETITION FOR REVIEW OF BS/MD PROGRESS NEOMED C1, C2, C3 STUDENTS INSTRUCTIONS: Please complete the online form. Sign the bottom of the page and submit your completed form to your university’s BS/MD coordinator. Failure to submit this petition will preclude any consideration of your BS/MD program continuation or other requests. DEADLINE: Forms are due April 15, 2015. 1. Student Name Last Name First Name M.I. Preferred First Name 2. Current Institution U of A KSU YSU 3. Address to send CAPP 1 outcome letter in late-June or mid-July for C1, C2, and C3 students. Street City State Zip 4. Area code & telephone number 5. Student Request. Please mark an “X” next to your request below: C1 Students C2 and C3 Students I request continuation in Phase 1 of the BS/MD program. I request to withdraw from the BS/MD program. Please add reason for withdrawal in the Personal Comments section (#8) below. I request continuation in Phase 1 of the BS/MD program. I request to be considered for promotion to Phase 2 of the BS/MD program. I request to withdraw from the BS/MD program. Please add reason for withdrawal in the Personal Comments section (#8) below. 6. Have you ever been placed on probation, suspended, disciplined, or been required to leave any college or university? No Yes. If yes, explain fully in personal comments section and submit with this petition all relevant documentation from the college or university involved. 7.a. Have you been convicted of, or pleaded guilty or no contest to, any criminal offense in a court of law since the date of signature on your application? No Yes. If yes, explain fully in personal comments section. Be specific including offenses, dates, etc. b. Have you been convicted of, or pleaded guilty or no contest to, any moving traffic violations since the date of signature on your application? No Yes. If yes, explain fully in personal comments section. Be specific including offenses, dates, etc. 8. Personal Comments - The space below provides you the opportunity to explain your situation for items 5-7, if applicable. 9. Certification - I certify that I have read and understand the document “Phase 1 Requirements.” I hereby petition for review of my Phase 1 progress. I affirm the information that I have provided on this petition is complete and accurate. I understand that any misrepresentation and/or omissions of facts on this petition may be cause for refusal of admission, cancellation of registration and/or suspension or dismissal from the program, the consortium university(ies) and/or NEOMED. ______________________________________________ ______________________________ Signature Date Revised 1/15