Admissions Application
Transition Doctor of Physical Therapy Program

All applicants must be a Master's level graduate of a CAPTE accredited program, have a current license and at least one year of clinical experience.

We welcome your application as a graduate student to Misericordia University.
Misericordia is dedicated to enhancing the professional success as well as the personal growth of each of its students. We trust that you will experience both a stimulating learning environment and a supportive "small campus" atmosphere while you are with us.

Application Procedure

1. Send a $25 non-refundable fee made payable to Misericordia University.
2. Submit official transcripts* from the accredited college/university where you received your bachelor's degree, and any additional college/ universities attended.
   *Misericordia University graduates do not need to submit Misericordia University transcripts.
3. Include a photocopy of your current Physical Therapy license(s).

Materials and Fee may be forwarded to:
Laree Brown
Adult Education
Misericordia University
301 Lake Street
Dallas, PA 18612

Please complete the form below and submit.

Name (Last)

(First)

(Middle)

Maiden or other surname(s) under which you earned credits

Date of Birth

Address:	Number Street
	City	State	Zip Code

Telephone:

Evening

Day

E-mail Address

Semester and year for which you are applying

Year

Fall

Spring

Summer

If applicable, what year did you graduate from the Misericordia University Physical Therapy Program?

Are you a dependent or spouse of a Misericordia University employee?

Yes

No

If Yes, please indicate the employee's name and title

Do you have a current license to practice Physical Therapy?

Yes

No

	If Yes, please list all current licenses
		State	License No.	Expiration Date
		State	License No.	Expiration Date
		State	License No.	Expiration Date

How did you initially hear about the Transition Doctor of Physical Therapy Program?
Word of Mouth	Alumni	Television
Radio	College Fair	Newspaper
College representative	Professional Journal	College Website
Other

Is there anything specific that influenced your decision to apply?

Education Data Degrees Held Please list degrees in reverse chronological order	Degree Institution Field of Study Date Conferred Degree Institution Field of Study Date Conferred Degree Institution Field of Study Date Conferred Degree Institution Field of Study Date Conferred
Employment Information	Employer Dates Employed Address Position/ Type of Work Responsibilities Employer Dates Employed Address Position/ Type of Work Responsibilities Employer Dates Employed Address Position/ Type of Work Responsibilities

The Civil Rights Office under Title VI requests that you check the category that best describes you. Check all that apply. (Optional)

African American	Hispanic	Other Please Specify
Multiracial	White
American Indian or Alaskan Native		Asian Hispanic

Your application will not be processed until all materials have been received.