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Application

Include City, State and Zip Code
Include area code
Include state and county
What is your country of citizenship?*
Include name and location (city and state)
enrollment to completion (ex. 1980-1984)
Include name and location (city and state)
enrollment to completion (ex. 1980-1984)
Include name and location (city and state)
enrollment to completion (ex. 1980-1984)
Include Practice type, Practice name, and years employed
Do you have any health care academic appointments?
Include Institution name, program type, type of academic appointment and number of years.
Include name of organization, position and years involved
Military experience
Are you active military?
Were you ever disciplined for academic performance or conduct violations (e.g. academic probation, dismissal, suspension, disqualifications, etc.) by any school or college?*
Have you ever been convicted of a felony or misdemeanor?*
Have you ever been subject to revocation of a professional license, or been censured, reprimanded or placed on probation for reasons relating to professional competence or conduct by a state licensing authority?*
Have you ever had disciplinary action taken against you by any professional society or professional association?*
Is there any information relevant to your ability to complete the Lincoln Memorial University, School of Medical Sciences, Doctor Medical Science program that LMU-DMS should consider?*
By submitted this application for consideration, I certify that all information provided on this application is true and accurate, complete and correct to the best of my knowledge and belief, and is made in good faith. I know and understand that any and all items contained herein are subject to verification and I consent to the full release of all information concerning my capacity and fitness for the educational program by employers, educational institutions and other agencies. I agree that providing inaccurate or false information or that failure to comply with University policy may result in disciplinary action, including dismissal. Throughout my enrollment, I agree to comply with the rules and regulations in the Lincoln Memorial University-School of Medical Sciences, Doctor of Medical Science student handbook and catalog.