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:
/ /
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:
/
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. /
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)
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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