The purpose of this study was to examine the relationship of performance on the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Level 1 licensing examination to (1) academic performance during the first 2 years of the curriculum, and (2) preadmission grade point averages (GPAs) and Medical College Admission Test (MCAT) scores for one osteopathic medical school with the unique mission of providing osteopathic family physicians for West Virginia and rural Appalachia. Simple correlations were calculated for the 63 students at West Virginia School of Osteopathic Medicine who completed all requirements of the first 2 years of the curriculum in May 1998 and were first eligible for board exams in June 1998. These included 26 (41.3%) female students and 5 (7.9%) minority students. Students who had failed a year and/or a course but subsequently successfully completed the first 2 years of the curriculum in May 1998 were included in this study. Every student who qualified to take the June 1998 administration of COMLEX-USA Level 1 did so at that time. For the 55 academic or preadmissions variables of interest, correlation coefficients with COMLEX-USA Level 1 scores and significance levels were calculated using SPSS Base 9.0. The correlation of COMLEX-USA Level 1 performance with GPA for Phase I was 0.64; with GPA for Phase II, 0.67; and total GPA for the first 2 years, 0.70. Grades in most individual courses also correlated significantly with COMLEX-USA Level 1 performance. Given the special focus of this curriculum on the needs of the Appalachian region and use of clinical performance measures or participation measures in calculating academic GPAs, these correlations show a remarkable degree of agreement between these two sets of performance measures. Further research is needed to see if similar relationships exist for osteopathic medical schools with other missions and with other curriculum structures. Preadmissions GPAs and MCATs did not significantly relate to performance on COMLEX-USA Level 1.