STUDENT PROFILE
Name (Last, First, M.I.) : ____________________________________________________
Home Address: ___________________________________________________________
City, State, Zip: ___________________________________________________________
Phone: ___________________________FAX (if available):_________________________
Campus Address:____________________________________________________
(If different)
City, State, Zip:______________________________________________________
Phone:________________________FAX (if available):_______________________
e-mail: ___________________________________________________________________
Date of Birth: _______________________ Place of Birth: ___________________________
Social Security: ____________________________________________________________
Please circle one: [Male] [Female]
U.S. Citizen? Yes ___No___ If no, please explain: ________________________________
What date will you be available?
First choice: ___________________________ Second choice: _______________________
Academic Experience (Chronological order, commencing with high school)
Name and Location of Institution ---- Dates Attended ----- Degree and Date
____________________________ ____________________ ___________________
____________________________ ____________________ ___________________
____________________________ ____________________ ___________________
____________________________ ____________________ ___________________
Employment (Chronological order commencing with high school)
Name of Employer & City ---------------------- Dates -----------------Position
__________________________________ ____________ ____________________
__________________________________ ____________ ____________________
__________________________________ ____________ ____________________
__________________________________ ____________ ____________________
Summary of Professional Experience (months):
Community Pharmacy: (Full time) _____________ (Part time) _______________
Hospital Pharmacy: (Full time) ______________ (Part time) ________________
Other, explain ________________________________________________________
How would you judge your experience at this point in the following areas?
(Please circle. 0 = none, 4 = extensive)
0 1 2 3 4 Dispensing
0 1 2 3 4 Compounding
0 1 2 3 4 O.T.C. Drugs
0 1 2 3 4 Patient Contact
0 1 2 3 4 Physician Contact (Personal) (Phone)
0 1 2 3 4 Patient Record Systems
0 1 2 3 4 Ordering and Receiving Stock
0 1 2 3 4 Medical and Surgical Accessories
0 1 2 3 4 Drug Information
0 1 2 3 4 Manufacturing or Bulk Compounding
0 1 2 3 4 Narcotic and Manufacturing Control
0 1 2 3 4 Intravenous Solutions
Using the above activities as a guide., briefly indicate what experience you think would benefit you most:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What organizations have you been involved in? (Student, professional, social. Include offices held and major committees.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What hobbies or out-of-school interests do you have?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please list the non-pharmacy school and social study courses you have taken:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Include an official copy of your transcript through June of your application year (3/5 or 4/6) of your program.
Three letters of recommendation are required for your application to be complete. One should be from your off campus coordinator giving an evaluation of you for the clerkship program, a letter of recommendation from one of your professors and one from an individual who you have had as a preceptor for internship hours. If you have not completed any internship hours by the time of applying, the letter can be from someone who employed you.
1. Name of Coordinator: _________________________________________________
Phone : _________________________________
2. Name of Professor: ___________________________________________________
3. Name of Preceptor/Employer: ___________________________________________
The following five questions should be answered and submitted with the application form.
1. How do you plan on using your pharmacy education after graduation? Explain.
2. What do you see as the one main issue facing pharmacy and/or health care in general over the next ten years. Explain.
3. How will completing a pharmacy clerkship with Mt. Edgecumbe Hospital help you in obtaining your professional goals? Explain.
4. Describe your concepts of Alaska.
5. In completing your intern hours to date, explain your practical experiences. What have you enjoyed the most and least? If you have not completed any intern hours prior to applying, pick a work experience and explain in the same manner.
Please return completed form to:
Traci Gale, Pharm.D.
Acting Director of Pharmacy
Mt. Edgecumbe Hospital
222 Tongass Dr.
Sitka, AK 99835
(907) 966-8347
FAX (907) 966-8450
e-mail: traci.gale@searhc.org
WEB: http://puffin.ptialaska.net/~pharmacy
updated 8-17-01