Application for Admission

Application for Admission to Palmer College of Chiropractic

This form has four sections: General Information, Educational Profile, Voluntary Information and Application Certification. Please fill out all required parts in full.

Note: If you are currently enrolled in a Doctor of Chiropractic program in another chiropractic college and are considering transferring to Palmer, please contact an Admissions Representative BEFORE completing this application.

After you are finished, press the "Submit to Office of College Enrollment" button at the bottom of the page.

Instructions for Application (D.C. Program)

General Information

Mark ONE circle to indicate the campus to which you are applying.

Have official transcripts from your last high school and all post-secondary institutions sent to the Office of College Enrollment. Transcripts and letters of recommendation will be held for 60 days without an application. 

It is recommended that applications be received at least one year prior to your anticipated entry date. Applications received later than 60 days prior to enrollment may not be considered.

All correspondence is sent to your "present" address. Please notify the Admissions Department of any changes immediately.

The "Home State" you list will appear in your graduation program.

For further information, call our toll-free number (800) 722-3648 or (563) 884-5656.

*required fields

*Which campus is right for me?

These files have been compressed to save as much download time as possible. The files can be viewed with Adobe Acrobat. Go to www.adobe.com to download the latest reader.

Catalog 
Key points 

Disclaimer: The Web site maintains the most current information, the printed catalog and matching pdf files are updated once per year.

Select Yes  I certify the information I submitted in my application form is correct and accurate. I have received, read and understand all information in the College Catalog and Key Points for the Doctor of Chiropractic Program document. If accepted, I agree to abide by all the rules and regulations in effect during my enrollment.

Today's Date:

*Month:

*Day:

*Year:

*Last Name:

*First Name:

Middle Name:

*Preferred Name:

*E-mail:

Alternate E-mail:

Previous Name:

Davenport Trimester:

San Jose Quarter:

Port Orange Quarter:

*Anticipated Entry Year:

*Street:

*City:

*State/Province:

*Zip/Postal Code:

*Country:

*Telephone (day/cell):

Telephone (night):

Permanent Mailing Address:

Street:

City:

State/Province:

Zip/Postal Code:

Country:

Telephone (day):

Telephone (night):

Personal Data:

*Date of Birth:

Nation of Birth:

*Home State:

*Are you a U.S. Citizen?

If no, specify Citizenship:

*Are you a U.S. Veteran?

*What is your U.S. Social Secruity Number? No dashes please

*Are you a permanent resident of the United States?

If yes, give place and date of entry (MMDDYYYY):

*Are you a foreign national now residing in the United States?

If yes, what is your visa status?

What is your Alien Registration number?

*Have you ever been convicted of, pled guilty or no contest to, or forfeited bail for any criminal conduct under law or ordinance, excluding only minor traffic violations?

If the answer is yes, please fully explain the circumstances:

Name:

Street:

City:

State/Province:

Zip/Postal Code:

Country:

Telephone (day):

Telephone (night):

Relationship:

How did you first hear of Palmer College of Chiropractic?

Family Member Relationship: Select One Parent Sibling Grandparent Aunt/Uncle  

Other  

Where else are you applying?

1.  

2.  

3.  

Name:

Address:

City, State, Zip:

Country:

Graduate of what chiropractic college:

Educational Profile

List the high school you graduated from and ALL colleges which you have attended (including chiropractic colleges), in order of earliest to latest/current. Do not abbreviate school names.

High School:

City:

State:

Year of Graduation:

If you received a G.E.D., please provide the location and date:

City/State:

Dates Attended:

Graduation Date:

Degree Received:

City/State:

Dates Attended:

Graduation Date:

Degree Received:

City/State:

Dates Attended:

Graduation Date:

Degree Received:

City/State:

Dates Attended:

Graduation Date:

Degree Received:

City/State:

Dates Attended:

Graduation Date:

Degree Received:

If you have attended more than 5 colleges, please enter the information for the other colleges here:

*Have you been dropped or dismissed from a college, graduate or professional school?

If the answer is yes, please fully explain the circumstances surrounding the dismissal or drop.

In submitting this Application for Admission, I agree and understand that I am to notify in writing the Admissions Department (either prior to acceptance or if accepted as a student) if I subsequently am dropped or dismissed from a college, graduate or professional school.

If prerequisite coursework is in progress or planned, please list the college at which you are taking each course, the course and the anticipated completion date below:

Do you anticipate entering Palmer with:

Voluntary Information

How would you describe yourself?

Gender:

Marital Status:

Married
Single

Widowed

Divorced  

Children  How many?  

Application Certification

Notice of Non-Discrimination and Reservation of Rights
In order to provide an environment that encourages respect, dignity and equal opportunity and is in compliance with applicable federal and state laws and regulations, Palmer College of Chiropractic and its respective colleges do not discriminate in employment or in educational programs, services or activities on the basis of age, race, creed, color, sex, national origin, ancestry, citizenship status, religion disability, veteran status or other characteristics protected by law. 

Palmer College of Chiropractic reserves the right, without notice, to modify its requirements for admission or graduation; to change the arrangements or content of its courses or the instructional materials used or the tuition and other fees charged; to alter any regulation affecting the student body; to refuse admission or re-admission to any student at any time, or to dismiss any student at any time, should it be in the interest of the College, or of the student, to do so. The College also reserves the right to change, without notice, any information conveyed in any and all College publications. It is the responsibility of the student to inquire about the currency and possible changes to all such information.

This application may be denied admissions based on a number of factors including, but not limited to, past academic performance, past academic or ethics violations, criminal activity or dishonesty in the admissions process. If you wish to withdraw your application at anytime, contact your Admissions Representative for processing.

*Credit Card#:

*Date of Expiration:

*Last Three Digits Above Signature Line on Back of Card (Am Ex four digit):

*Amount of charge:

• complete autobiography 
• official transcripts received directly from all post-secondary institutions
• copy of high school diploma or official copy of high school transcripts

You may wish to obtain one Letter of Recommendation   from a Doctor of Chiropractic and one from a faculty from a post-secondary class you have attended. Two letters of recommendation on letterhead are recommended but not required. These may accompany your application or be mailed separately. Ask the referents to write a candid letter about the qualities you possess that will enable you to be successful in both academic and professional settings. Have them include their name, position, phone number, address and signature, as well as your name and Social Security number. They may mail the recommendations directly to the Office of College Enrollment at 1000 Brady Street, Davenport, IA 52803.

We encourage you to complete the FASFA form at your earliest convenience.

*Please note: You may wish to waive your right (under Family Education Rights and Privacy Act of 1974) to review letters of recommendation. Such action is optional. 

Yes. I waive my right to review recommendations and evaluation in support of my application. 

This stands as written permission for those other than myself, listed below, to access my file. 
(example: parent/significant other name)

*Select Yes   I am submitting this form which serves as my authorization to Palmer College of Chiropractic to process my application.

I certify that the foregoing information is true and complete to the best of my knowledge and realize that failure to provide official transcripts and other required information may result in the cancellation of admission or registration.

I understand that revocation of this application must be made in writing and sent to the Office of College Enrollment at Palmer College of Chiropractic.

You are submitting your application for admission to Palmer College when you click submit.

E-mail key code:  (leave blank if unknown)