1. International-Trained PharmD (ITPD) Program
APPLICATION FOR ADMISSION
University of Colorado
Skaggs School of Pharmacy and Pharmaceutical Sciences Building
Distance Degrees and Programs
12850 E. Montview Boulevard, Room V20-1116
Aurora, CO 80045
Mail Stop C238-V20
Phone: 303-724-3582
iPharmD@ucdenver.edu
Please
iPharmD@ucdenver.edu.
type all information in the form below and submit the application electronically utilizing the Adobe Acrobat® signature
process. If signed electronically, your application will be sent directly to the DDP Office. If you choose to provide a physical
signature, please submit the completed application with your signature to
Summer 2015 (Deadline: January 15, 2015) Summer 2016 (Deadline: January 15, 2016)
Check the appropriate box for your anticipated semester of entry. If date falls on a weekend or holiday, the deadline is the following business day.
The application fee is $200.00.
Legal Name __________________________________________ __________________________________________
Last Name/Family Name/Surname First Name
__________________________________________ __________________________________________
Middle Name Preferred Name/Nickname
Other Names (Please list other names that may appear on your academic records): ________________________________________
National Identification Number (if available) __________________________________________
Examples: Social Security Number (US), Social Insurance Number (Canada)
Passport Number ______________________________________ Country _________________________________________
Permanent Address _________________________________________________________________________________________
Number and Street or P.O. Box
__________________________________________ ___________ __________ ____________________
City State/Province Postal Code Country
Primary Phone (__________) ___________________________ Secondary Phone (__________) __________________________
Country code Telephone Country code Telephone
E-mail: _____________________________________________________________________________________________________
Mailing Address ____________________________________________________________________________________________
(If different from permanent address) Number and Street or P.O. Box
__________________________________________ ___________ __________ ____________________
City State/Province Postal Code Country
How did you hear about the ITPD Program? ____________________________________________________________________
The following information is voluntary and is used for statistical purposes only.
Age and Birth Date: _________ _____/_____/_____ Gender: Male Female Marital Status: Married Single
Age Mo Day Year
Birthplace ______________________________ ______________________________ Number of Dependents ________________
City State or Country
Select one category that most accurately reflects your ethnic background
American Indian or Alaskan Native _______________________________________ ___________________________
Tribal Affiliation Enrollment Number
Asian American Hawaiian Native or Polynesian White, not of Hispanic Origin
Black or African American, not of Hispanic Origin Hispanic, Chicano, Mexican American, Latino I do not wish to provide this information
Choose one or more of the ethnic terms in the list below that further or better describes your ethnic background.
African American Caribbean Islander East Indian Hawaiian Native Latino Puerto Rican
American Indian Caucasian Eskimo Hispanic Mexican Samoan
Asian Indian Chicano Filipino Japanese Micronesian Thai
Black Chinese Guamanian Korean Pakistani White
Cambodian Cuban Haitian Laotian Polynesian Vietnamese
Other ________________________
Please select:

2. 2
ADDITIONAL INFORMATION
Pharmacy Licensure or Certificate
List state(s)/province(s)/country(s) in which you hold a license to practice pharmacy.
State/Province/Country License Number License Status
Has your license to practice pharmacy ever been suspended or revoked? Yes No
If yes, you must include a separate explanation with this application.
Criminal Record
Have you ever been convicted of a felony, or local equivalent, or are you under the terms of a deferred judgment? Yes No
If yes, you must include a separate explanation with this application.
Citizenship
U.S. Citizen (If you are a U.S. citizen born outside of the United States you must provide a copy of your U.S. passport or
Certificate of Naturalization.)
Permanent Resident (Immigrant)
Alien Registration Number_________________________________ Date of Issue________________________________________
Non Immigrant on Temporary Status / Country of Citizenship_________________________________________________
COLLEGE AND UNIVERSITY INFORMATION
List the pharmacy school(s) from which you graduated and any degree program(s) in which you have been enrolled since obtaining
your degree in pharmacy. Official transcripts from each institution must be received by the application deadline. Please request
college transcripts 8-12 weeks prior to the application deadline.
Name of Institution
City and State/Province
and Country
Dates of Attendance
(Mo/Year)
Degree /Date
Earned
Language of
Instruction
Type of
System*
Hours
Completed
*Type of system: Semester (S), Quarter (Q), Trimester (T), Other (O).

3. 3
PROFESSIONAL PHARMACY EXPERIENCE
Attach a copy of your current resume or curriculum vitae including pharmacy work/practice since graduating with a bachelor of
pharmacy degree (or equivalent).
Have you served as a preceptor for pharmacy students? Yes No
If yes, list dates: ________________________________________________________________________________________
List any honors or awards received while in pharmacy school or since graduation from pharmacy school (including honorary
societies).
______________________________________________________________________________________________________
______________________________________________________________________________________________________
List professional presentations and the group to which you presented, and/or the titles and citations for any posters, journal articles,
publications, inventions or creative work.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
List memberships, offices held and/or committee participation in professional organizations.
Membership, Office or Committee Society Dates
LETTERS OF RECOMMENDATION
Please provide the names of three individuals (not related to you) who know you well, have agreed to submit recommendations and
are in a position to objectively judge your professional, academic and/or personal qualities. Recommendations must be provided by
professional contacts, such as employers, supervisors, former faculty, preceptors or professional colleagues. References from clergy,
family members, friends or politicians will not be accepted. For purposes of consistency, you must use the standard University of
Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs recommendation form.
Letters submitted in lieu of the recommendation form will not be accepted.
Recommendation #1 Recommendation #2
Name Name
Title Title
Relationship Relationship
Recommendation #3
Name
Title
Relationship

4. 4
PROFESSIONAL SPONSORSHIP
Please provide the name of the individual who has agreed to serve as your professional sponsor. A professional sponsor (typically an
employer), will attest to their support of your pursuit of the degree program, and your plans for expanding the practice of patient-
centered pharmacy care outside the United States. This sponsorship does not require financial sponsorship. If the professional sponsor
is also serving as a reference they must submit a letter of recommendation and a professional sponsor letter.
Professional Sponsor
Name
Title
Relationship
PERSONAL STATEMENT OF PROFESSIONAL GOALS
Attach a personal statement (please submit a typed document (4 pages maximum) using 12 point font, double-spaced, on A4 paper).
In your personal statement, please address the following questions:
• Why are you interested in obtaining a PharmD from the University of Colorado Skaggs School of Pharmacy and
Pharmaceutical Sciences? What would you do to advance pharmacy’s role in patient-centered care outside of the United
States?
• What is your plan for completing the online curriculum? Specifically, how will you find the time to complete the required
coursework?
• Students in the ITPD Program will be required to come to the United States at the beginning of the program for 4 weeks. At
the end of the program, students will return for a minimum of 30 weeks to complete the remaining portion of the didactic
curriculum and rotation experiences. The 30 week timeframe is based on completing the didactic curriculum and rotation
experiences back-to-back; however, students are not required to complete all rotations in one visit. Considering that:
o What is your plan for completing the clinical rotation experiences in the United States?
o How do you think this will impact you, your family, your current employer, your finances, etc.?
• What is your planned timeline for completing all necessary coursework and graduation?
SIGNATURE
I hereby certify, to the best of my knowledge, that the information furnished on this application is true and complete without
omission or misrepresentation of facts, and I attest that my statement of professional goals is a document of my own
authorship. Furthermore, if any changes occur in the information furnished on this application during the application process
or while I am a student at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, I understand
that I am required to report the changes to the University of Colorado Skaggs School of Pharmacy and Pharmaceutical
Sciences Distance Degrees and Programs Office within one month. I understand that if I do not adhere to these standards, it is
sufficient cause for rejection or dismissal.
______________________________________________ _____________________
Signature of applicant Date
Thank you for completing the admissions form. The Distance Degrees and Programs Office will contact applicants to schedule
an appointment to complete the interview, which will be conducted via video teleconference.

5. 5
CHECKLIST FOR APPLICATION
To streamline the application process, applicants are encouraged to submit the application and recommendation forms online.
All other documents, including the application fee, should be assembled in an application packet and sent to the Distance
Degrees and Programs Office in a single mailing.
All applicants need to submit the following items by January 15th:
Application Fee – the $200 (US) non-refundable application fee in the form of a check or money order made
payable to the University of Colorado. Make sure the applicant's name and student or social security number
appears on the front of the check or money order. All fees should be made payable in US dollars.
Pharmacy License – notarized or barrister-certified copy of your current pharmacy license(s)/certificates.
Documents in a foreign language must be translated by an approved translation service.
Professional History – resume or curriculum vitae including pharmacy work/practice since graduating with a
pharmacy degree (or equivalent).
Personal statement and professional goals.
Recommendations – three recommendations provided on the standard University of Colorado Skaggs School of
Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs recommendation form. Completed
forms should be emailed directly to the Distance Degrees and Programs office at ipharmd@ucdenver.edu.
Professional sponsorship– one professional sponsorship provided on the standard University of Colorado Skaggs
School of Pharmacy and Pharmaceutical Sciences Distance Degrees and Programs professional sponsorship
form. Completed forms should be emailed directly to the Distance Degrees and Programs office
at ipharmd@ucdenver.edu.
Transcripts – request official transcripts from the school of pharmacy from which you graduated and from any
degree program(s) in which you have been enrolled since obtaining your degree in pharmacy. The official transcripts
must be evaluated and translated by an approved agency and sent directly to the Distance Degrees and Programs
(DDP) Office.
TOEFL Exam – Visit www.ets.org/toefl to find more information about the exam and to sign up for the exam.
Please use code number 8776 to indicate the University of Colorado Skaggs School of Pharmacy iPharmCU™ as
the score recipient.
Competency exam or FPGEE – complete and pass the competency exams or provide proof of a passing FPGEE
score. Scores for exams taken prior to 2003 will not be accepted. If completing the competency exams, applicants
should submit the Test Authorization Request Form at least 5 business days prior to testing. Applicants should
provide a notarized copy of the FPGEE score.
Upon review of all applications, candidates selected to continue the admissions process will need to complete:
Oral Proficiency Interview (OPI) – the DDP Office will provide selected applicants with directions to complete a
30-minute OPI by telephone as a portion of the evaluation of English proficiency.
Written Essay – the DDP Office will provide selected applicants with directions to complete a written essay as a
portion of the evaluation of English proficiency.
Interview – the DDP office will contact selected applicants with directions to schedule and complete an admission
interview via teleconference. An offer to interview may not be extended to all applicants.
The Distance Degrees and Programs Office will send an acknowledgement and status report to each applicant within six weeks of
receiving their application. Applicants will be notified of any missing elements in their application packet and will be given the
opportunity to correct deficiencies that are beyond their control.
Please keep the Distance Degrees and Programs Office informed of any address, phone, or email changes so we may contact you if
the need arises (email: iPharmD@ucdenver.edu or phone 303-724-3582). Thank you for your application.