College of Dentistry > Students

PERSONAL DATA:

Last Name First Name MI

Permanent Address

Street

City State Zip

Country

Present Address

Street

City State Zip

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 Issue
License Number

EDUCATIONAL BACKGROUND:Undergraduate

University or College		Location

Dates Attended	Major	Degree	GPA	Date Received

University or College		Location

Dates Attended	Major	Degree	GPA	Date Received

Dental

University or College	Location

Dates Attended	Major	Degree	GPA	Date Received	Class Rank

University or College	Location

Dates Attended	Major	Degree	GPA	Date Received	Class 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 I	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
1.
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

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?

CERTIFICATION STATEMENT

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.

Send comments to Al Kaplan, Last Modified: August 25, 2006
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