To submit completed form: save and email to paprogram@bw.edu, or print and fax to (440) 826-3830.
(If you are using a Mac, please complete this form in Adobe Acrobat Reader and not Preview.
If you don’t have the Acrobat Reader, you can download it at https://get.adobe.com/reader/.)
This form will be reviewed upon verifying that Shadowing Form/s have also been submitted as required.
Last Name ___________________________________________________________________ First Name____________________________________________
Preferred Mailing Address ________________________________________________________________________Email __________________________________
PREREQUISITES
Candidates for the PA Program must complete all approved prerequisite courses as listed below. Please indicate when you completed these courses, plan to
complete, or enroll in them. Courses in a I & II sequence reflect semester courses, or a full year of that subject. If courses were taken as quarter credits, then three
courses (i.e., a full year sequence) are required. For any courses retaken, include information for both enrollments.
Prerequisite Course
Type of Course
Course Number
(e.g., ENG 100)
Term/Year
(e.g., FA17, SP18)
University / College
Grade
Earned
English Composition
Statistics
General Psychology
General Biology I with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
General Biology II with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
General Chemistry I with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
General Chemistry II with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
Organic Chemistry with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
Microbiology with lab
Lecture OR
Lecture & Lab
Lab (if separate
course number)
Anatomy & Physiology I with lab
OR
Anatomy w/ lab*
Lecture OR
Lecture & Lab
Lab (if separate
course number)
Anatomy & Physiology II with lab
OR
Physiology w/ lab*
Lecture OR
Lecture & Lab
Lab (if separate
course number)
Medical Terminology
*One full semester of human anatomy with lab and one full semester of human physiology with lab can replace the anatomy and physiology combined courses.
BALDWIN WALLACE UNIVERSITY
Physician Assistant Program Master of Medical Science (MMS)
Application Supplement Form
FOR ALL PREREQUISITE COURSEWORK - COMPLETED, IN PROGRESS, AND PLANNED
Were all courses and labs taken in traditional, in-person format? Yes No
If No, please list the course/s and a brief description of the format (i.e., hybrid, on-line, etc.); include the course number/s shown on the previous page of this form:
DEGREE(S) EARNED / TO BE EARNED
University / College
Degree
Major
Date
ENROLLMENT INFORMATION
1. Have you previously applied to Baldwin Wallace University? No Yes, Dates__________________________________________________________
2. Do you plan to apply for financial aid (FAFSA)? No Yes
BACKGROUND INFORMATION
1. Have you ever been found responsible for a disciplinary violation at any college you have attended, whether related to academic or behavioral misconduct that
resulted in your probation, suspension, removal, dismissal or expulsion from the institution? No Yes
2. Have you ever been found guilty or convicted of a misdemeanor or felony that was not expunged or sealed? No Yes
Note: Although students with an expunged record may be eligible for enrollment and clinical placement in BW’s
program, an expunged record may impact a student’s eligibility to qualify for a professional license following
completion of the program. Eligibility for a professional license varies by state and may be assessed on a
case-by-case basis by the professional licensing board.
3. Have you ever tested positive for drug or alcohol use on a urine drug screen? No Yes
If you answered ‘Yes to any of these BACKGROUND INFORMATION questions, please use the space below to give the approximate date and location of each
incident, with explanation of the circumstances of each incident.
REQUIRED ACKNOWLEDGMENT
Please click on box to express agreement with statements and thereby allow for processing of your Application Supplement.
I hereby certify that all information in my application is factually true and honestly presented. I understand that any misrepresentation may be cause for denial or
cancellation of admission.
Date: _____________________________________