Fillable Form 1.: DEANS CERTIFICATION Applicant Instructions This form (Medical College of Wisconsin)

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Form 1.: DEANS CERTIFICATION Applicant Instructions This form (Medical College of Wisconsin)

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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. It is also required if you have
previously matriculated at a medical school regardless of the reason for departure.
Conduct violations include, but are not limited to, institutional student conduct code violations as well as on-
campus housing policy violations.
1.
Please provide a statement explaining the following information if you were ever subject to any
action by any postsecondary educational institution (e.g. undergraduate, graduate,
professional, 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.
If you have previously matriculated at a medical school, please describe the circums
tances
contributing to your leave including, but not limited to, unacceptable academic performance or
conduct violation(s). Please describe what has changed since this situation that will support your
success if admitted.
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 MCW 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 situation, violation,
outcome, and/or related corrective measures?
Yes No
Email:
Additional Explanation, if needed:
Institution:
Office:
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 medschool@mcw.edu. 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.
If no, please provide provide an
accurate account of the circumstance.
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Form 1.: DEANS CERTIFICATION Applicant Instructions This form (Medical College of Wisconsin)

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Completed 23 August 2020

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