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    Application for Advanced Education in Periodontics

    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.

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