School of Dental Medicine: Online Application

Advanced Standing Advanced Education in General Dentistry
Dental Anesthesiology Endodontics
Oral and Maxillofacial Pathology Periodontics
    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:
/ /
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:
Day/Work Telephone:
Home Telephone:
Dates at this address:
Optional Information:

African American Asian/Pacific Islander
American Indian/Alaskan Native Hispanic
Caucasian Other
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. /
2. /
3. /
4. /
5. /
6. /
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. /
2. /
3. /
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)
I certify that the information in this application is complete and correct to the best of my knowledge and belief.