School of Dental Medicine: Online Application
Program
:
Advanced Standing
Advanced Education in General Dentistry
Dental Anesthesiology
Endodontics
Oral and Maxillofacial Pathology
Periodontics
Prosthodontics
Other
If other, please specify:
Biographical Information:
Last Name:
First Name:
Middle Initial:
U.S. Social Security Number
(or Canadian Social Insurance #):
Email Address:
Date of birth:
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Country of Birth:
Are you a U.S. citizen?
Yes
No
If not, please indicate:
Country of Citizenship:
City of Visa Issue:
Visa type:
Present Address
Street Address Line 1:
Street Address Line 2:
City:
state:
Zip:
Day/Work Telephone:
Home Telephone:
Dates at this address:
From:
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To:
/
Optional Information:
Ethnicity:
African American
Asian/Pacific Islander
American Indian/Alaskan Native
Hispanic
Caucasian
Other
Sex:
Female
Male
Academic Information:
Please list, in chronological order, all colleges and professional schools previously attended. Include undergraduate, graduate, and dental schools.
College
Time Attended
Major
GPA/Class Rank
Graduation Date
1.
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2.
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3.
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4.
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5.
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6.
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TOEFL Scores:
The Test of English as a Foreign Language (TOEFL), is required of all applicants for whom English is not their first language or who have not attended at least four years of school in an English-speaking institution immediately preceding this application. Please list TOEFL scores, if required, Official scores must be submitted as well
Examination Date
TOEFL Score
1.
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2.
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3.
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Academic and Professional Activities:
Please check activities in which you have participated.
Research
Academic Honors
Teaching
Private Practice
Military / Public Health
Post-Graduate Education (specify below)
Specify:
I certify that the information in this application is complete and correct to the best of my knowledge and belief.
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Signature