Application Date:	May 25, 2013
Applying for admission to the Professional Program beginning: Fall   2013 2014 2015
Full Name:	First:   Middle:   Last:
Current Address:	City:   State:   Zip:
Permanent Address:	City:   State:   Zip:
Home Phone:
Work Phone:
SSN:
E-mail:
Have you applied for or been admitted to the University of Mary?      If you have not applied for the University of Mary admission, do so immediately;      call (701) 355-8390 or 1-(800)288-6279
Applied    Admitted    Have Not Applied
Are you a citizen of the United States?      (A non US citizen student is required to provide a copy of his or her visa no later than two weeks prior to beginning classes.)
Yes    No

College/University	Dates Attended From (Month/Year) - To (Month/Year)	Degree	Overall GPA

The graduate respiratory therapy program requires extensive reading comprehension, analysis and writing skills; please rank your ability in this regard on the scale below:     1   2   3   4   5   6   7   8   9   10 Poor     Average       Excellent

Applicants for admission to the Master of Science Respiratory Therapy Program must meet the following minimum qualifying criteria: Earned baccalaureate degree from a regionally accredited college or university with an overall grade point average (GPA) of 3.00 or higher A 3.00 or higher GPA in the respiratory therapy program's prerequisite pre-professional courses in math, biology, chemistry, physics, pharmacology, ethics, English (communications) and social sciences, with no individual course grade below a "C." Three letters of reference from individuals able to judge the applicant's ability to perform graduate level work.

Three letters of reference are required, two of which must be from undergraduate college professors from whom you took one or more courses in your senior year, and one of which can be from another college professor from whom you took one or more courses, or an academic advisor, or other college official in a position to judge your ability to perform graduate work. Instruct your references to send their letters to:   Respiratory Therapy Program Education/Technology Building St. Alexius Medical Center 900 East Broadway Bismarck, ND 58502

The Respiratory Therapy Program has a policy regarding the admission of persons with a criminal history. A criminal record does not automatically preclude admission. The nature of the crime will be considered on a case-by-case basis, including subsequent rehabilitation. Applicants are required to answer all of the questions below. An affirmative response to any question requires you to provide additional information, which will be reviewed by the Admissions Committee and the St. Alexius Human Resources department. Falsification or omission of information may result in a denial of admission, rescission of admission, dismissal from the program, or other appropriate action. Please answer all questions "yes" or "no:"
Yes    No	1. Are you currently named as defendant in a criminal proceeding for mistreatment, neglect, or abuse of any person, or misappropriation of property?
Yes    No	2. Have you ever been convicted of a felony or misdemeanor for mistreatment, neglect or abuse of any person, or a misappropriation of any property?
Yes    No	3. Have you ever been convicted of any other felony or misdemeanor?
Yes    No	4. Have you ever been dismissed and/or suspended from a college or university because of conduct?
If yes to any of the above, please explain:
By checking the box to the left, I hereby certify that this attestation contains no misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my privileges as a student at St. Alexius Medical Center will be revoked immediately. In the event my criminal history should change while I am participating as a student or faculty, appropriate notification will be provided to my school and St. Alexius Medical Center.

List extracurricular activities and organizations in which you have participated as a student, including elected or leadership positions.

List community organizations, including activities and leadership roles, in which you have participated.

List major jobs you have held since graduating from high school.

Please attach a personal essay, not to exceed 500 words, showing how your background, experiences and values have prepared you to be successful at the graduate level and as a healthcare professional.   Essay: