Army National Guard

Interservice Physician Assistant Program (IPAP) Academic Worksheet

______

Last Name, First Name, Middle InitialSSN MOS / AOC

State POC e-mail address:

Other names listed on transcripts:______Date completed:______

Part I. List all colleges and universities attended and the dates of attendance(semester and year, e.g. Fall 1996) Must have an official transcript from each institution forwarded to NGB prior to application deadline.

College / University and Location Dates of Attendance Total # of Credits Degree

Part II. List all course work currently in progress.

College / University and Location Course in Progress Anticipated date of completion

Part III. List all courses attempted, including those failed, under the appropriate heading. List the semester hours (Sem Hrs) of each course. Quarter (QTR) hours should be converted to semester hours according to the following scale:

QTR Hours SEM HoursQTR Hours SEM Hours

1 .764.0

21.374.7

32.085.3

42.796.0

53.3

Technical courses such as typing, welding and courses taken for certification (Emergency Medical Technician or Licensed Practical Nursing) are not accepted. Do not list these courses.

List additional courses on a continuation sheet if the sections do not provide sufficient space.

English and Literature

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Biological Sciences

(Anatomy & Physiology, Biology, Microbiology, Genetics, Immunology, etc.)

Course Title Sem Hrs / Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Chemistry

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Other Science Courses

(Physics, Botany, Nutrition, Geology, Geography, Astronomy, etc)

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Mathematics

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Psychology

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Humanities and Social Sciences

(Government, Art, Education, Philosophy, History, Languages, Anthropology, Civilization, Music, Speech, Ethics, )

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Other Courses

(Business, Economics, Law, Computer Sciences, CLEP, DANTES, etc.)

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

SUBJECT GPA: ______

Graduate Courses

Course Title Sem Hrs Grade College Date Completed

(Semester & Yr)

1