CAMPUS: (CHECK ONLY ONE) ☐ Grand Rapids ☐ Traverse City

Requests must be submitted with supporting documentation. Include copies of unofficial transcript from ALL schools attended.

√ Type of Request Supporting Documentation 5-Year Course Requirement Waiver… check all that

apply ▪ Brief, detailed statement indicating when and

where you took the class along with what you have been doing to keep your knowledge base of the course material up-to-date.

▪ Resume (if applicable) ▪ Actual documentation of course (i.e. unofficial

transcript(s))

☐ Biochemistry ☐ Human Anatomy

☐ Human Physiology ☐ Microbiology

Prerequisite Substitution… check all that apply ▪ Provide course description and syllabus ▪ Brief, detailed statement indicating when and

where you took the class along with reasoning for request.

▪ Actual documentation of course completion (i.e. unofficial transcript(s))

☐ General Biology ☐ General Chemistry ☐ Genetics ☐ Organic Chemistry ☐ Biochemistry ☐ Human Anatomy

☐ Human Physiology ☐ Statistics ☐ Psychology ☐ Microbiology ☐ Physics

Course Completion Extension The following courses MUST be completed at time of application:

▪ Brief, detailed statement indicating the reason or circumstance for the request

▪ Supporting documentation (Requires letter from academic advisor or registrar confirming reason that course has not been completed) ▪ Copy of unofficial transcript(s)

☐ Organic Chemistry ☐ Biochemistry ☐ Human Anatomy

☐ Human Physiology ☐ Microbiology

Other Request (write in type of request below)

▪ Brief, detailed statement indicating the reason for the request

▪ Supporting documentation

GVSU PAS Admissions Committee Official Recommendation The decision made by this committee is final.

Date/Initial Status Remarks Approved

Conditionally Approved

Denied

Grand Valley State University Physician Assistant Studies (PAS)

Admissions Academic Request Form Name: ________________________________ Date: _______________________

GVSU G# (if applicable): ________________________________

Email: _______________________________ Phone: _______________________

2020 Fall Application Academic Request Deadline

July 15, 2020

For consideration for fall 2020 application cycle, which ends September 1, 2020, this completed form, and necessary supporting documentation, must be received by GVSU PAS Admissions Committee at

ellisji@gvsu.edu on or before July 15, 2020. Please allow 4-6 weeks for processing.