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Application for Advanced Education in Orofacial Pain

For Class entering

Personal Data:

Last Name:First Name:MI

Permanent Address

Street:

City:

State: Zip:

Country:

Present Address

Street

City

StateZip

Country

E-mail Address:

(Please keep us informed of address changes)

Date of Birth (mm/dd/yy)

Ethnic Background (voluntary)

Gender

Daytime Number

Evening Number

Social Security Number

Citizenship

 

State Dental Licenses:

State

Year of IssueLicense Number


State

Year of Issue License Number


State

Year of Issue License Number

 

Educational Background: Undergraduate

 

University or College

Location
Dates Attended

Major Degree GPADate Received

 

University or College

Location

Dates Attended

Major DegreeGPADate Received

 

Dental

University or College

Location

Dates Attended

MajorDegreeGPA

Date ReceivedClass Rank

 

University or College

Location

Dates Attended

MajorDegreeGPA

Date ReceivedClass Rank

 

Graduate Record Examination (GRE) Series

Verbal

Quantative

Analytical

Date Taken(mm/dd/yy)

 

National Dental Board Examination Scores

Part 1

Ana

Bch/Phy

Micro/Path

Dent Ana

Avg

Date Taken(mm/dd/yy)

 

Part 2

Score

Date Taken(mm/dd/yy)

Test of English as a Foreign Language (TOEFL) Score.

Score

Section 1

Section 2

Section 3

Total

Date Taken(mm/dd/yy)

 

General Practice Residency

Location

Dates Attended

 

Honors Received

1.

2.

3.

4.

5.

Extracurricular Activities

2.

3.

4.

5.

Research Experience

1.

2.

3.

4.

 

Publications

1.

2.

3.

4.

 

PROFESSIONAL ACTIVITIES:

Society and service club activities

1.

2.

3.

4.

5.

6.

 

Resume of Dental Practice

 

Other employment since graduation

1.

2.

3.

4.

Professional references: One reference must be from an administrative office of the dental school from which you graduated. This letter should include information like class standing, scholastic average and/or your potential for graduate study. A second reference should be from the chairman of the dental school department specializing in your area of interest.

Name

Position

 

Name

Position

 

Name

Position

 

Name

Position

We request that you ask those listed above to write letters of recommendation in your behalf.

Professional Goals:

Why are you interested in advanced dental education; what are your career goals?

 

Why does the program at Kentucky attract you?

By submitting this electronic application, I certify that the information contained herein is complete and accurate. I understand that withholding information or giving false information makes me ineligible for admission to and enrollment in a University of Kentucky College of Dentistry Post Graduate Program.