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University of Kentucky College of Dentistry

International Fellowship in Periodontology/Implantology

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

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

National Dental Board Examination Scores (If Taken)

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)

Extracurricular Activities
1.
2
3.
4.
5.

Research Experience
1.
2.
3.
4.

Publications
1.
2.
3.
4.

Employment since graduation
1.
2.
3.
4.

PROFESSIONAL GOALS:

Why are you interested in the International Fellowship Program; what are your career goals?

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: December 2, 2010
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