School of Dental Medicine: Online Application
Advanced Education in General Dentistry
Oral and Maxillofacial Pathology
If other, please specify:
U.S. Social Security Number
(or Canadian Social Insurance #):
Date of birth:
Country of Birth:
Are you a U.S. citizen?
If not, please indicate:
Country of Citizenship:
City of Visa Issue:
Street Address Line 1:
Street Address Line 2:
Dates at this address:
American Indian/Alaskan Native
Please list, in chronological order, all colleges and professional schools previously attended. Include undergraduate, graduate, and dental schools.
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
Academic and Professional Activities:
Please check activities in which you have participated.
Military / Public Health
Post-Graduate Education (specify below)
I certify that the information in this application is complete and correct to the best of my knowledge and belief.