1.Were you ever the recipient of any institutional action (e.g., disciplined, probation, suspended, dismissed or other action) by any college, university or medical school for unacceptable academic performance or conduct violation, even though such action may not have interrupted your enrollment or required you to withdraw? If ‘Yes’ please explain fully in the space below.

2.Have you ever participated in a pre-conviction program, or been convicted of a felony or other criminal offense, or pled guilty or no contest to a felony or other criminal offense? Include information even if charges have been dropped, dismissed, or otherwise mitigated. If yes, please explain below.

3.Have you ever been convicted of or pled guilty or no contest to any moving traffic violations (moving violations include speeding tickets)? If yes, please explain fully below (include information even if charges were dropped, dismissed, or otherwise mitigated).

4.Have you ever matriculated at or attended any medical school as a candidate for the M.D. degree? If yes, please explain below.

5.(If you are not currently a full time student) Provide a thorough explanation of all activities planned between now and your matriculation into medical school.

6.Are you a UCCOM re-applicant? Explain how you and your application have changed since your previous submission, and tell us what you have learned along the way.

7.Discuss any elements of your application that you feel might be concerning to the Admissions Committee. (This could include explanation of metric trends, institutional actions, legal violations, etc.). Please enter N/A if you have no concerns to report.

8.What is your specific interest in the UCCOM program? What opportunities would you take advantage of as a student here? Why?

9.Do you have a personal connection to Ohio? If ‘yes’ Please describe.