Does anyone have WashU's Dean's Certification Form from past applications?

[jaygatsby]

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I know that WashU requests a Dean's Certification letter from the applicant's undergrad that would basically detail what institutional actions have been taken against the applicant. I also know that WashU provides a form to submit to the Dean or whoever that handles these. I was wondering, is there anyone out here who has previously applied to WashU that could give me a link or download for that form? I'd like to submit it but request that the results be sent to myself. I'm basically doing this in response to LizzyM's comment in another thread (http://forums.studentdoctor.net/showthread.php?t=320856):

You'd certainly want to check the certification to be sure that it is accurate regarding your record on campus. Like a credit report, incorrect information could derail you and you would never know why unless you had access to the document.

 

[Diallelus]

The Dean writes everything on another piece of paper and just signs the form. The form itself gives you no information about what the Dean will write; it just asks for all relevant information in your judicial history.

What I'm saying is that the form will not help you. You need to talk to your Dean of Students / Student Affairs.

 

[jaygatsby]

The Dean writes everything on another piece of paper and just signs the form. The form itself gives you no information about what the Dean will write; it just asks for all relevant information in your judicial history.

What I'm saying is that the form will not help you. You need to talk to your Dean of Students / Student Affairs.

Well, from searching, this is what I found was typed on the form:

To the official representing the institution: The individual named above is applying to Washington University School of Medicine. In selecting students for the study and practice of medicine, we aim to accept only people who possess high moral character and integrity that is requisite for the practice of medicine and justifies the trust that will be placed in them. Accordingly, please provide candid answers to the following questions and return this information to the address listed at the bottom of this page. Please add narrative comments as you see fit. Please note that no action can be taken on this person’s application until this form is returned. Thank you for your time and help.

Has the applicant been the subject of previous or pending disciplinary action or proceedings for misconduct? (Check Yes or No). Please provide an explanation for an affirmative answer. Use the reverse side or attach additional pages if needed.

I just wanted to do this as officially as possible (so I wanted to actually find the form PDF or whatever) so that I know I'll be seeing exactly what the school sees. I do see your point though.

 

[Diallelus]

Certification by Current Dean of Students or Comparable Administrative Official

Applicant Name: _____________________________________________________________________

Birth date ____________ SSN:__________________ AAMC ID:_____________________

I understand that federal law provides me with a right of access to this certification which I may waive, but no one can require me to waive this right.
I waive do not waive my right of access to this certification.

I authorize the official representative of the below named institution to provide a candid evaluation and all relevant information including the release of disciplinary records.

Applicant signature (required): _____________________________________ Date:___________

To the official representing the institution: The individual named above is applying to Washington University School of Medicine. In selecting students for the study and practice of medicine, we aim to accept only people who possess high moral character and integrity that is requisite for the practice of medicine and justifies the trust that will be placed in them. Accordingly, please provide candid answers to the following questions and return this information to the address listed at the bottom of this page. Please add narrative comments as you see fit. Please note that no action can be taken on this person's application until this form is returned. Thank you for your time and help.
Has the applicant been the subject of previous or pending disciplinary action or proceedings for misconduct? Yes* No * Please provide an explanation for an affirmative answer. Use the reverse side or attach additional pages if needed.
Institution:____________________________________________________________ name, city and state
Name of official:_____________________________________ Title: ________________________________
(Please Print)

Phone:__________________________________ Email: ________________________________

Signature (required):________________________________________ Date: ______________

 

[Diallelus]

It's not in PDF form, but there it is, cut and paste from the website.

Hope you have better luck than I did at WashU (let's go waitlist!).

 

[jaygatsby]

Thanks. I really appreciate it.