DEAN’S CERTIFICATION Applicant Instructions This form is required if you have answered “yes” to either the Institutional Action question on your AMCAS application and/or your MCW Medical School Secondary application. Conduct violations include, but are not limited to, institutional student conduct code violations as well as oncampus housing policy violations. 1. Please provide a statement explaining the following information if you were ever subject to any action by any educational institution (i.e. undergraduate, graduate, or medical school) for unacceptable academic performance or conduct violation: Exact nature of unacceptable academic performance or conduct violation Specific circumstances contributing to unacceptable academic performance or conduct violation Result action(s) taken by institution Corrective measures resulting from institutional recommendations or personal initiative 2. Present your statement along with the attached form to an appropriate academic Dean’s Office at the institution where the action occurred. Ask the Dean’s Office to complete the form and send it directly to the MCW Medical School Office of Admissions along with your statement. The Admissions Committee reviews applications based upon completion date of application. Your application will not be considered complete until your statement and Dean’s Certification have been received. DEAN’S CERTIFICATION Please type or print legibly. Applicant Name: Applicant Statement: AAMC ID: DEAN’S CERTIFICATION Please type or print legibly. Applicant Name: AAMC ID: To the Dean or Academic Officer: The individual whose name appears on this form is an applicant for admission to the Medical College of Wisconsin Medical School. Please provide a candid evaluation of the applicant’s record at your institution. Has the applicant ever been disciplined by your institution? Yes No Has the applicant ever been placed on academic probation? Yes No Does the attached statement that the applicant provided accurately reflect the circumstances of the violation, outcome, and related corrective measures? Yes No If no, please provide provide an accurate account of the circumstance. Institution: Office: Email: Phone: Name of official completing this form: Title: Signature: ______________________________________ Date: _______________ Scan the completed form along with the applicant’s statement, and email to the MCW Office of Admissions at [email protected] This form is a required part of the applicant’s application. The application will not be considered complete without this form. Thank you for your assistance.
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