This form will be used as the basis for letters of recommendation for scholarships, jobs, etc., throughout your time at DMS. If you are in the Brown-Dartmouth Program, the Dean's letter in support of your transfer into the third-year class at Brown will be taken largely from this information. If you will be at DMS for all four years, this form, plus an update on your activities during medical school, will serve as the basis of your Dean's letter of recommendation to residency programs.

Your Name:

Father's name, profession, and place of employment:

Mother's name, profession, and place of employment:

Your Age:

Birthplace

Where did you grow up?

High School

What high school did you attend?

Class rank, if known:

Academic honors (please indicate reasons for honors and year presented):

Non-athletic extracurricular activities with years, e.g. committees, musical activities, offices held, etc.:

Athletics--both formal and informal--that you participated in, any related honors/positions, and years (freshman, junior, etc.):

Other activities not covered above, such as volunteer work, community service, travel, etc. Please include the number of hours devoted to the activity.

Employment during the academic year. State hours/week and which year(s). What did you do?

What did you do during summers? If employed, indicate hours/week and which summers.

Did you take any time off between high school and college? If yes, please give reasons/particulars.

College

If you attended more than one college, please provide information on first college as A and the college from which you received your degree as B; if only one college, jump to B.

Academic honors (please indicate reasons for honors and year presented):

Research during college:

Dates: Name and title of professional with whom you worked: Type of laboratory and location (institution): Brief description of the work you did: Did this work result in articles, abstracts, or presentations? If so, please provide the citation for journal articles or dates/locations of presentations.

Non-athletic extracurricular activities with years, e.g. committees, musical activities, offices held, etc.:

Athletics--both formal and informal--that you participated in, any related honors/positions, and years (freshman, junior, etc.):

Other activities not covered above, such as volunteer work, community service, travel, etc. Please include the number of hours devoted to the activity.

Employment during the academic year. State hours/week and which year(s). What did you do?

What did you do during summers? If employed, indicate hours/week and which summers.

If you took time off between undergraduate school and medical school, what did you do? Graduate School? Research? Employment? Travel? Other? Please provide details.

Related Publications? Give citation(s).

Medical School

What was the driving force that influenced your decision to pursue a career in medicine?

What do you consider your strengths and any characteristics/experiences which you feel distinguish you from other students?

Visualize yourself 10 years from now.

What will you be doing? Teaching? Research? Family?

What, besides medicine, do you feel you must be involved in or committed to 10 years from now?