Centenary College of Louisiana
Personal Information Form
Application Must Be Typed
If a student meets the criteria to use the Centenary College Premedical Committee and chooses to utilize the
services of the Committee, it is understood that the Committee Evaluation is confidential and accessible only to
the Committee and the schools the student has listed on this Personal Information Form. I also understand that
these evaluations are not for purpose of applying for scholarships. I further understand that in choosing to use
the Centenary College Premedical Committee, I waive my right to view the committee evaluation. Please note,
it is the student’s choice to utilize the Centenary College Premedical Committee for evaluation of application to
medical/dental schools. It is not a requirement.
Signature ______________________________________________ Date ____________________
Full Name ___________________________________ Age _____ SS No. ____________________
Permanent Address ____________________________________ Phone _____________________
City_________________________________ State _______ Zip________________
Centenary Address ____________________ Phone ______________ Email ___________________
Applicant for: Medicine Dentistry Other ___________________________________
Are you applying to an Early Decision Program? yes no Graduation Date __________
Are you currently enrolled at Centenary? yes no Last semester attended? ___________
Major(s) __________________________________ Minor(s) ________________________________
Overall GPA _________ Science GPA _________
MCAT/DAT Scores _____________________________ Date(s) _________________
Medical/Dental schools that you will apply. The schools listed must be the same as those on your
AMCAS/AADSAS applications. If schools are added later, you must notify us in writing. Please list
the schools by state.
School City/State
______________________________________________ _________________________________
______________________________________________ _________________________________
______________________________________________ _________________________________
______________________________________________ _________________________________
______________________________________________ _________________________________
______________________________________________ _________________________________
List names of faculty from whom you will request evaluations. The list should include at least two science (each
from a different science) and one non-science faculty member who actually taught you on the Centenary
campus. A minimum of three and a maximum of five. This form may also be used by off-campus evaluators.
Evaluator Name Department
1. _________________________________________ ___________________________________
2. _________________________________________ ___________________________________
3. _________________________________________ ___________________________________
4. _________________________________________ ___________________________________
5. _________________________________________ ___________________________________
1. Write a paragraph about your alternate plans if medical/dental school study is not feasible for you.
2. If we asked your best friend about your personality, what would she or he say are your strengths
and weaknesses?