DEAN`S CERTIFICATION Applicant Instructions This form is required

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.