Deferment of Admisison

Deferment of Admission
Applicant Name*

First NameMiddle NameLast Name
Doctor of MedicinePremedical Sciences
I request defer my entry from*

MonthDayYear
Date
I request defer my entry to*

MonthDayYear
Date
Reason for requesting a deferment*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Deferment of Admission Fee*

Deferment of Admission Fee

I understand that a nonrefundable fee of US $100.00 is to be paid in order to maintain my application file on hold for a period of one (1) term. This fee must be paid at the time of the deferment application. Furthermore, the seat deposit of US $500 is non-refundable if I decide not to enroll with UHSA.

$100.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*
Any payments made in accordance with this form submission shall, once they are paid, not be refundable nor creditable for any reason whatsoever.
Should be Empty: