KSTAR Physician Assistant Assessment Application

Assessments are two days on site at the Texas A&M Health Science Center campus in Bryan, Texas, and are individually tailored to meet each physician assistant's needs. Assessments may include but are not limited to: standardized patient encounters, record review, multiple choice testing, cognitive screening, and physician discussions and interviews.
Applicant Information
Name Name First Last
Phone Phone - ### - ### ####
Email
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Work Phone Work Phone - ### - ### ####
Work Address Work Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female
In what country were you born?
What is your first language?
What is your second language?
Do you have a history of substance abuse?

Do you have a history of substance abuse? Yes No
What type of abuse?
Are you currently enrolled in a treatment/monitoring program?

Are you currently enrolled in a treatment/monitoring program? Yes No
Please provide the name of the Treatment program and contact information.
How long have you been drug/alcohol free?
Have you ever been convicted of a felony?

Have you ever been convicted of a felony? Yes No
Please give a summary of your felony conviction, including the date
Education Information
College
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
College
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Degree
Start Date Start Date / MM / DD YYYY
Graduation Date Graduation Date / MM / DD YYYY
Please explain any time off or delays in school.
Did you experience any disciplinary problems in school?

Did you experience any disciplinary problems in school? Yes No
Please explain any disciplinary problems in school.
Did you experience any academic problems in school?

Did you experience any academic problems in school? Yes No
Please explain any academic problems in school.
Certified in:
Post Graduate Education
Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please list all other credentials such as ACLS, PALS, etc.
Practice Information
List all states in which you are licensed to practice medicine.
Has a license to practice medicine requested or possessed by you ever been denied, restrictes, suspended, revoked or voluntarily surrendered in any state? Please explain
Are you currently in practice?

Are you currently in practice? Yes No
Referral Source
I am self-referred and have not been referred by any third party I was referred for an assessment by a third party
Certification

I certify that I agree to participate in the KSTAR program and understand that a formal contract arrangement, to include fees, will be initiated before I am considered to be enrolled in the program.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Application fee

The application fee of $350 may be paid paid by check or credit/debit card.
Payment Information

Credit/Debit Cards are accepted online through the Texas A&M payment gateway.

Or, mail a check to:
A&M Rural and Community Health Institute
2700 Earl Rudder Freeway South, Suite 3000
College Station, Texas 77845
Checks made out to TAMHSC

If you have any questions, contact Tracy Adams at 979-436-0407 or tladams@tamu.edu.

KSTAR Physician Assistant Assessment Application

Applicant Information

Education Information

Post Graduate Education

Practice Information

Referral Source

Certification

Application fee

Payment Information