UT Martin Pre-Med Scholars Program Application
Fall 2022
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Preferred Name
Name in Banner (if different from above)
Pronouns
UTM ID
E-Mail
Home Address
Hometown
Telephone #
Major(s)
Academic Advisor
Class as of Fall 2022
Based on number of semesters on campus, not on number of credits
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Main area of interest
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When do you plan to apply medical school?
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When do you plan to take the MCAT?
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Extracurricular Activities
Honors or awards while in college
Any situation which may have affected or will affect your work during any semester?
e.g. athletics, off campus employment, etc.
Any special academic projects, honors courses, etc.
Any other information which might be helpful in completing your evaluation.
Faculty reference (Name, Department, E-Mail)
Because we may or may not know you well, we would like to ask a UT Martin faculty member about you.  Please list the name and contact information of a faculty member at UTM who know you well and/or with whom you have a good relationship.  It is advisable to check with the faculty member before listing him/her to make sure he/she is comfortable providing a brief reference for you.  
Why do you want to be a physician?
Please keep your answer as concise as possible (between 100 and 300 words).
What qualities should a good physician possess and how do you demonstrate those qualities?
Please keep your answer as concise as possible (between 100 and 300 words).
I give permission to release my Pre-Med Scholars application as well as my cumulative GPA; my grades in Chemistry 121 and 122 and Biology 130 and 140; and the highest math class I have completed to the physicians or their designees who are participating in the UT Martin Pre-Med Scholars Program.
The participating physicians may be consulted on the final selection of participants; however, because they are not UT Martin faculty or staff, they are not allowed access to your private information.  In order for them to help us make the best decisions possible, we would like to release your academic information (i.e., your cumulative GPA; your grades in Chemistry 121 and 122 and Biology 130 and 140; and the highest math class you have completed) to them. Please indicate below whether or not you are willing to allow UT Martin to release your academic information to the participating physicians and then sign.  I must have an original signature to release your information.
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