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Graduate Information Form

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GRADUATE INFORMATION FORM
Fields marked with "*" are required.

Full Name:

Prefix:		First:*
Last:*		Middle:

Student ID Number:*

Parents' Name:*

Parents' Address:

Street:*
City:*		County:*
State:*		Zip:*
Phone Number:	- -
Email Address:

Mailing Address Following Graduation:

Street:*
Apt./P.O. Box #
City:*		County:*
State:*		Zip:*
Phone Number:	- -
Email Address:*		Fax:

Degree:* Major:*

Relatives who attend or have graduated from USP. (Please give relationship and class year, if known).

High School Attended and Year Graduated:

List All post secondary degrees (including USP degree/s):

Degree	Major	Institution Name	Year Received

If accepted into a Graduate or Professional degree program, please indicate institution and degree expected:

If you would like for your hometown daily and/or weekly newspapers to be notified about your graduation information, please indicate the publication(s) where a press release should be sent:

List activities such as memberships in professional and social organizations on campus (include office held). For example, class offices, Student Government; Dormitory Council; Fraternities; intramural athletics; etc.:

List academic honors, including scholarships and appointment to Deans' list (note consecutive semesters if applicable):

List intercollegiate athletic team membership:

Plans after graduation:

(a)

If you will be employed full-time, please list employer's name and location and title of your position:

(b)

Profession Description: (i.e., Hospital, Retail, Industry, Acute Care, Academic, PT etc.)

(c)

If you will not be employed full-time, are you: (Please check one)

	completing internship at
	looking for a job
	pursuing post graduate degree at
	entering a full-time residency at

For statistical information, please indicate your starting salary range:

	Under $25,000		$45,001 to $50,000
	$25,001 to $30,000		50,001 to $55,000
	$30,001 to $35,000		$55,001 to $60,000
	$35,001 to $40,000		$60,001 to $65,000
	$40,001 to $45,000		$65,001 to $70,000
			$70,001 and over

THIS SECTION FOR PHARMACY GRADUATES ONLY.
IF YOU ARE NOT A PHARMACY GRADUATE, PLEASE SKIP THIS SECTION.

Degree Received May 2007: PharmD Flex PharmD

Where are you expecting to become licensed? (Check all that apply)

PA NJ DE MD Other, specify:

Which one of the following provides the best description of your current employment status?

As of today, I have a pharmacy related position (check area below) which I will retain, or have retained, beyond my licensure as a pharmacist. (Describe only primary position, if you have more than one position)

Pharmacy Practice	Pharmaceutical/ Health Industry	Other Settings
Chain Pharmacy	Basic or Clinical Research	College/University
Independent Pharmacy	Product Development	Consultant
Mail Order Pharmacy	Marketing Sales, Advertising	Other (specify)
Hospital/Institutional Pharmacy	Drug/Medical Information
Long Term Care/Nursing Home	Education/Training
Home Care, Home Infusion	Medical Writing
Managed Care	Regulatory
Consultant Pharmacist	Other (specify):

Because I am pursuing advanced education or training, I am currently not seeking a permanent employment position. (Check program of study below)

Residency, General or Pharmacy Practice

Residency, Specialty, Please specify specialty:

Fellowship, Please specify specialty:

Graduate and/or Professional Program (check area below)

PhD MS or MA MD or DO DDS DVM

MPH or DPH MBA LLD or JD Other (Specify):

As of today, I do not have a pharmacy related position.

If you checked #1 or # 2, please answer the following questions:

What is the name of your employer?
Name : City, State :

Which of the following best describes your major job responsibilities?

Professional or Other Staff	Manager, Administrator
Owner, Entrepreneur	Other (specify):

Based on your experience, how easy do you feel it was to obtain a position coming out of school?
Very easy Easy Somewhat easy Not very easy

The information you have provided may be incorporated by the Deans in letters of recommendation you authorize. The Director of University Relations will also issue press releases to local papers in your area unless you instruct us to withhold the information.

Thank you for your cooperation.

Date: Name:



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GRADUATE INFORMATION FORM Fields marked with "*" are required.

GRADUATE INFORMATION FORM
Fields marked with "*" are required.