undergraduate application

The application and all pertinent forms should be on file with the Undergraduate Studies office at least four weeks prior to the beginning of the desired starting academic term. Students are encouraged to submit their application at least six months prior to their desired term of entry.

* Required

Bachelor of Science, General Science Completion Program

* Anticipated Entry * * First Name Middle Name * Last Name Preferred Name Previous First Name Previous Middle Name Previous Last Name * Email * Phone (use dashes)

Check if not US Phone Number

Secondary Phone

Check if not US Phone Number

Mailing Address (for all correspondence)

* Street * City * State / Province * Postal Code * Country Is this your Permanent Address?

Permanent Address Street City State / Province Postal Code Country

Background Information

* Date of Birth (MM / DD / YYYY) Birth Nation * U.S. Citizen

U.S. Citizens * Social Security Number U.S. Military Service?

Non-Citizens * Visa Status Registration Number

Emergency Contact: Name, Relationship and Contact Information (1 - 2 people)

Educational Information

* How did you hear about us?

Referral information Family Member Relationship Other

List all institutions you have attended (chronologically). Do not abbreviate.

High School City State Year of Graduation (YYYY) G.E.D. location and date Have you attended College?

College Information College * City State Dates Attended (MM/YYYY) to Graduation Date (MM/YYYY) Degree Received Add College

College #2 College * City State Dates Attended (MM/YYYY) to Graduation Date (MM/YYYY) Degree Received List Additional Colleges... Remove College

Additional Colleges Remove

* Have you been dismissed from school?

Please Explain... *

Are you planning, or currently taking, prerequisite coursework?

Prerequisites Please list the college, course name and the anticipated completion date.

Completed Semester Hours to date

Voluntary Information

Ethnicity Other Gender Marital Status Number of Children

Who was most influential in your decision to apply?

Name Address City State Postal Code Country Graduate of... Do you have any relatives who are graduates of Palmer?

Department of Undergraduate Studies
Palmer College of Chiropractic
1000 Brady Street
Davenport, Iowa 52803-9989

Undergrad@palmer.edu

Terms and Conditions

I am submitting this form which serves as my authorization to Palmer College of Chiropractic to process my application.
I certify the information submitted is true and complete to the best of my knowledge and I am not knowingly excluding information that may cause undo delay or denial of my application.
I understand that my supporting documents will be held for 30 days without an application.
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.
I understand that I am to notify the Admissions Department in writing, if I am dropped or dismissed from a college, graduate or professional school.
I give permission for Palmer College to collect and store my information for processing and contact purposes and understand that my privacy is protected.
Note: This stands as written permission for those other than myself, listed below, to access my file. Others Access
I understand that my application will not be processed until I have paid the $150 non-refundable application fee by clicking on an option below.

* Payment Method

Card Payment

Amount to be charged: $150.00

Please check if you are paying with a card not issued in the United States

Payer's Zip Code

Make checks payable to

Palmer College of Chiropractic

Mail to:

Department of Undergraduate Studies
Palmer College of Chiropractic
1000 Brady Street
Davenport, Iowa 52803-9989

Account holder (if other than you)

Notice of Non-Discrimination and Reservation of Rights

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Notice

Notice of Non-Discrimination
Palmer College of Chiropractic (College) does not discriminate in employment, admissions or in educational practices, programs, services or activities on the basis of age, ancestry, citizenship status, color, creed, disability, national origin, race, religion, sex, sexual orientation, gender identity, veteran status or other characteristic protected by law in the state in which the applicable College premise is located.

Reservation of Rights
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 and the instructional materials used, or to alter any regulation affecting the student body; to refuse admission or readmission 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 same right as to any other material in this publication.

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.

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Application Procedures
Applicants are promptly notified as documents are received and each step of the application is completed. Only written communication directly from Undergraduate Studies shall be considered official. Acceptance is based on the approval of the completed file. Applicants will be notified of their current status. The balance of the first academic term tuition is due on orientation day. If the applicant does not begin Palmer in the academic term requested and Undergraduate Studies is unable to make contact, the file will be destroyed. The prospective student must then reapply and resubmit all necessary documents.