From Practice to Preceptor Program (FP2P) Application for Admission

Size: px
Start display at page:

Download "From Practice to Preceptor Program (FP2P) Application for Admission"

Transcription

1 From Practice to Preceptor Program (FP2P) Application for Admission Personal Data Name Permanent Address Mailing Address (if different from above) County Telephone Number Please Complete All Information If New Jersey Resident, how long? Cell Number General and Dental Education List all post-secondary and dental schools attended, including dates of attendance and degree(s) awarded. Post-Secondary School s of Attendance Major Degree(s) & Awarded Professional Experience(s) List all professional experience(s) subsequent to completing dental school. School or Hospital s of Attendance Course/Residency/Internship Certificate/Degree & List any private practice or other dental related employment experience subsequent to completing dental school. Location Type of Practice/Employment Full/Part Time s Associate s Name (if applicable) List any academic distinctions, fellowship, scholarships, awards or prizes. List any research or teaching experience (including non-dental related)

2 List community service activities within the last two years: Dental Licensure License Issued by State of Issue (m/y) Expiration (m/y) License # Additional License(s) Type License Issued by State of Issue (m/y) Expiration (m/y) License # Narcotics Certification NJ CDS # Issue (d/m/y) Expiration (d/m/y) NJ DEA # Issue (d/m/y) Expiration (d/m/y) National Provider Identifier (NPI #) Number Board Certification Specialty Board Sub-Specialty Board Medicaid/Medicare # (If applicable) Number CPR Certification (CPR certification is mandatory and a prerequisite for participation in the program) CPR Certification Expiration : (Attach copy of current certification card) Please read and understand the statement of Essential Functions, which all applicants must satisfy for the program of study to which they are applying, with or without reasonable accommodation. I acknowledge that Rutgers School of Dental Medicine has established these requirements for completion of the program. If I require an accommodation, I will do so promptly and in writing. Please initial Have you ever been subject to disciplinary action by any professional licensing board? Yes No If yes, please explain. Has your license to practice ever been suspended or revoked? Yes No If yes, please explain.

3 Are you a Veteran? Yes No Do you come from a disadvantaged* background? Yes No *Disadvantaged background includes: (educationally) coming from an environment that has inhibited the individual from obtaining knowledge, skills, and abilities required to enroll in and graduate from a health professions school. For example, graduating from a high school with low graduation rate, low rate of graduates attending college, low SAT scores, low per capita funding, and/or high rates of eligibility for free or reduced price lunches. Additionally, an individual who is first generation in a family to attend college is considered educationally disadvantaged. (economically) coming from a family with an annual income below a level based on low income thresholds according to family size. For example, coming from a family that receives public assistance (e.g., Aid to Families with Dependent Children, food stamps, Medicaid, public housing) or family that lives in an area that is designated under section 332 of the Act as a health professional shortage area. How did you hear about the FP2P Program? Web search Word of mouth Continuing Dental Education website Continuing Dental Education mailing NJDA ADA Bulletin RSDM mailing (FP2P brochure) RSDM FP2P website Other: Responses to these questions are voluntary, will be kept confidential and will not affect the status of your application. Do not wish to report Male Race: American Indian or Alaska Native Ethnicity: Hispanic or Latino/a Female Asian Not Hispanic or Latino/a Black or African American Native Hawaiian or Other Pacific Islander White More than one race

4 Use this space to discuss the following: 1. The reasons for your interest in academic dentistry: 2. How does this program fit in with your short and long-term professional/career goals?

5 References 3 are required. A letter of evaluation will be sent directly to the named reference (A maximum of one reference can be from a Rutgers employee) Name Address Phone I hereby authorize the three individuals named above who are familiar with my education and employment history to provide information to Rutgers School of Dental Medicine. I hereby voluntarily waive any and all rights I may have to privacy and/or confidentiality pertaining to my education and employment history insofar as the information is released solely to those who are evaluating my suitability for admission to a faculty training program. This authorization shall remain valid for 90 days from the date of signature. I have read the above, understand its contents, and voluntarily agree to its terms. Signature Printed TERMS AND CONDITIONS: Acceptance into this program does not constitute an offer of employment or imply a promise of future employment. Participants are required to maintain a current, active license to practice dentistry in the State of New Jersey during the entire term of the program and must notify program administration of any events adversely affecting licensure. Participants must provide evidence of meeting immunization requirements of Rutgers Biomedical and Health Sciences. By entering my initials in the box below I verify the information entered by me is true and accurate to the best of knowledge. I also agree to the terms and conditions of this application (listed above). Revised June 2014

UW-Waukesha Pre-College Program. College Bound Take Charge of Your Future!

UW-Waukesha Pre-College Program. College Bound Take Charge of Your Future! UW-Waukesha Pre-College Program College Bound 2017 Take Charge of Your Future! This is a great program to increase your knowledge on various subjects. Students will be engaged in workshops and hands-on

More information

APPLICANT INFORMATION. Area Code: Phone: Area Code: Phone:

APPLICANT INFORMATION. Area Code: Phone: Area Code: Phone: MARQUETTE UNIVERSITY HEALTH CAREERS OPPORTUNITY PROGRAM College Science Enrichment Program (CSEP) & Pre-Enrollment Support Program (PESP) Website: http://www.mu.edu/hcop INSTRUCTIONS: Please type or print

More information

New Student Application. Name High School. Date Received (official use only)

New Student Application. Name High School. Date Received (official use only) New Student Application Name High School Date Received (official use only) Thank you for your interest in Project SEARCH! By completing the attached application materials, you are taking the next step

More information

KENT STATE UNIVERSITY

KENT STATE UNIVERSITY KENT STATE UNIVERSITY Regents STARTALK Teacher Leadership Academy: Chinese, Russian Director: Brian J. Baer / Co-director: Theresa A. Minick Program Dates: Thursday, July 7 - Saturday, July 16 Summer 2016

More information

DUAL ENROLLMENT ADMISSIONS APPLICATION. You can get anywhere from here.

DUAL ENROLLMENT ADMISSIONS APPLICATION. You can get anywhere from here. DUAL ENROLLMENT ADMISSIONS APPLICATION SM You can get anywhere from here. Please print or type: DUAL ENROLLMENT APPLICATION Last Name First Name Maiden/Middle Social Security # Local Address (include apt.

More information

Emergency Medical Technician Course Application

Emergency Medical Technician Course Application Community Health Network Emergency Medical Technician Course Application January 2018 First day of Class January 8,2018 EMERGENCY MEDICAL SERVICES & EDUCATION Thank you for your consideration in choosing

More information

Institution of Higher Education Demographic Survey

Institution of Higher Education Demographic Survey Institution of Higher Education Demographic Survey Data from all participating institutions are aggregated for the comparative studies by various types of institutional characteristics. For that purpose,

More information

University of Utah. 1. Graduation-Rates Data a. All Students. b. Student-Athletes

University of Utah. 1. Graduation-Rates Data a. All Students. b. Student-Athletes University of Utah FRESHMAN-COHORT GRADUATION RATES All Students Student-Athletes # 2009-10 Graduation Rate 64% 64% Four-Class Average 61% 64% Student-Athlete Graduation Success Rate 87% 1. Graduation-Rates

More information

Bellevue University Admission Application

Bellevue University Admission Application Bellevue University Admission Application Bellevue University is an open admissions university. Once you submit your application, we will begin the process of evaluating your credits and developing your

More information

ADULT VOCATIONAL TRAINING (AVT) APPLICATION

ADULT VOCATIONAL TRAINING (AVT) APPLICATION Attention Education Department AVT 2468 West 11 th Eugene, OR 97402 ADULT VOCATIONAL TRAINING (AVT) APPLICATION The following documents or information will be required to complete the application: Documents

More information

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science

California State University, Los Angeles TRIO Upward Bound & Upward Bound Math/Science Application must be completed in black or blue ink only. STUDENT INFORMATION Name: Social Security # - - First Middle Last Address: Apt.# Phone: ( ) City: State: Zip Code: Date of Birth: Place of Birth:

More information

SMILE Noyce Scholars Program Application

SMILE Noyce Scholars Program Application ONLINE POST-BABACCALAUREATE TEACHER PREPARATION PROGRAM SMILE yce Scholars Program Application Introduction: Rio Salado College is soliciting applicants for the Science and Math Innovative Learning Environments

More information

Meeting these requirements does not guarantee admission to the program.

Meeting these requirements does not guarantee admission to the program. .Eastern Connecticut State University, School of Education & Professional Studies Committee on Admission and Retention in Education (CARE) UNDERGRADUATE ELEMENTARY Teacher Certification Application Application

More information

University of Arizona

University of Arizona Annual Report Submission View Questionnaire (Edit) University of Arizona Annual Report Submission for the year 2009. Report has been submitted 1 times. Report was last submitted on 11/30/2009 7:12:09 PM.

More information

Freshman Admission Application 2016

Freshman Admission Application 2016 We are pleased that you have requested application materials from Governors State University. We recommend that you review all program requirements carefully. Major requirements may vary. Please review

More information

EMPLOYMENT APPLICATION Legislative Counsel Bureau and Nevada Legislature 401 S. Carson Street Carson City, NV Equal Opportunity Employer

EMPLOYMENT APPLICATION Legislative Counsel Bureau and Nevada Legislature 401 S. Carson Street Carson City, NV Equal Opportunity Employer EMPLOYMENT APPLICATION Legislative Counsel Bureau and Nevada Legislature 401 S. Carson Street Carson City, NV 89701-4747 Equal Opportunity Employer Read Instructions Before Proceeding I am applying for

More information

Best Colleges Main Survey

Best Colleges Main Survey Best Colleges Main Survey Date submitted 5/12/216 18::56 Introduction page 1 / 146 BEST COLLEGES Data Collection U.S. News has begun collecting data for the 217 edition of Best Colleges. The U.S. News

More information

Table of Contents. Internship Requirements 3 4. Internship Checklist 5. Description of Proposed Internship Request Form 6. Student Agreement Form 7

Table of Contents. Internship Requirements 3 4. Internship Checklist 5. Description of Proposed Internship Request Form 6. Student Agreement Form 7 Table of Contents Section Page Internship Requirements 3 4 Internship Checklist 5 Description of Proposed Internship Request Form 6 Student Agreement Form 7 Consent to Release Records Form 8 Internship

More information

12-month Enrollment

12-month Enrollment 12-month Enrollment 2016-17 Institution: Potomac State College of West Virginia University (237701) Overview 12-month Enrollment Overview The 12-Month Enrollment component collects unduplicated student

More information

Shelters Elementary School

Shelters Elementary School Shelters Elementary School August 2, 24 Dear Parents and Community Members: We are pleased to present you with the (AER) which provides key information on the 23-24 educational progress for the Shelters

More information

Information and Instructions

Information and Instructions Application for Admission: Radiation Therapy Certificate Program The University of North Carolina Hospitals Department of Radiation Oncology Information and Instructions 1. Use this application only for

More information

Port Graham El/High. Report Card for

Port Graham El/High. Report Card for School: District: Kenai Peninsula Grades: K - 12 School Enrollment: 20 Title I School? No Title 1 Program: Accreditation: Report Card for 2008-2009 A Title 1 school receives federal money in support low-achieving

More information

File Print Created 11/17/2017 6:16 PM 1 of 10

File Print Created 11/17/2017 6:16 PM 1 of 10 Success - Key Measures Graduation Rate: 4-, 5-, and 6-Year 9. First-time, full-time entering, degree-seeking, students enrolled in a minimum of 12 SCH their first fall semester who have graduated from

More information

Upward Bound Math & Science Program

Upward Bound Math & Science Program Upward Bound Math & Science Program A College-Prep Program sponsored by Northern Arizona University New for Program Year 2015-2016 Students participate year-round each year beginning in 2016 January May

More information

Application for Full-Time Freshman Admission

Application for Full-Time Freshman Admission Application for Full-Time Freshman Admission About You Biographical Information Name Fill in legal name exactly as it appears on official documents. Are you a New York State resident? First/given name

More information

Cooper Upper Elementary School

Cooper Upper Elementary School LIVONIA PUBLIC SCHOOLS http://cooper.livoniapublicschools.org 215-216 Annual Education Report BOARD OF EDUCATION 215-16 Colleen Burton, President Dianne Laura, Vice President Tammy Bonifield, Secretary

More information

Duke University. Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke

Duke University. Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke Office Use Only Durham, North Carolina Application Fee $30 received Trinity College of Arts & Sciences/ Pratt School of Engineering Application for Readmission to Duke BEFORE completing this application,

More information

Data Diskette & CD ROM

Data Diskette & CD ROM Data File Format Data Diskette & CD ROM Texas Assessment of Academic Skills Fall 2002 through Summer 2003 Exit Level Test Administrations Attention Macintosh Users To accommodate Macintosh systems a delimiter

More information

Student Mobility Rates in Massachusetts Public Schools

Student Mobility Rates in Massachusetts Public Schools Student Mobility Rates in Massachusetts Public Schools Introduction The Massachusetts Department of Elementary and Secondary Education (ESE) calculates and reports mobility rates as part of its overall

More information

ADULT VOCATIONAL TRAINING PROGRAM APPLICATION

ADULT VOCATIONAL TRAINING PROGRAM APPLICATION Ph: ADULT VOCATIONAL TRAINING PROGRAM APPLICATION Applicant: Enclosed is the application packet you requested for the Adult Vocational Training Program (AVT). If you are a first time applicant, the AVT

More information

Status of Women of Color in Science, Engineering, and Medicine

Status of Women of Color in Science, Engineering, and Medicine Status of Women of Color in Science, Engineering, and Medicine The figures and tables below are based upon the latest publicly available data from AAMC, NSF, Department of Education and the US Census Bureau.

More information

Iowa School District Profiles. Le Mars

Iowa School District Profiles. Le Mars Iowa School District Profiles Overview This profile describes enrollment trends, student performance, income levels, population, and other characteristics of the public school district. The report utilizes

More information

West Hall Security Desk Attendant Application

West Hall Security Desk Attendant Application West Hall Security Desk Attendant Application Mail Completed Application To: Office of Residence Life Attn: SDA Application 100 State Street, PO Box 9101 Framingham, MA 01701-9101 OR Drop Off Completed

More information

Please complete these two forms, sign them, and return them to us in the enclosed pre paid envelope.

Please complete these two forms, sign them, and return them to us in the enclosed pre paid envelope. Anatomical Donation Program Jack and Pearl Resnick Campus 1300 Morris Park Avenue, Rm F627N Bronx, NY 10461 Phone: 718.430.3142 Fax: 718.430.8997 anatomical.gifts@einstein.yu.edu We sincerely thank you

More information

Information Packet. Home Education ELC West Amelia Street Orlando, FL (407) FAX: (407)

Information Packet. Home Education ELC West Amelia Street Orlando, FL (407) FAX: (407) Information Packet Home Education ELC 8 445 West Amelia Street Orlando, FL 32801 (407) 317-3314 FAX: (407) 317-3211 www.schoolchoice.ocps.net Orange County Public Schools Home Education Program (HEP) Revised

More information

2. Related Documents (refer to policies.rutgers.edu for additional information)

2. Related Documents (refer to policies.rutgers.edu for additional information) Policy Name: Clinical Affiliation Agreements Approval Authority: RBHS Chancellor Originally Issued: Revisions: 6/20/13 1. Who Should Read This Policy All Rutgers University research faculty and staff within

More information

Kansas Adequate Yearly Progress (AYP) Revised Guidance

Kansas Adequate Yearly Progress (AYP) Revised Guidance Kansas State Department of Education Kansas Adequate Yearly Progress (AYP) Revised Guidance Based on Elementary & Secondary Education Act, No Child Left Behind (P.L. 107-110) Revised May 2010 Revised May

More information

Frank Phillips College. Accountability Report

Frank Phillips College. Accountability Report Frank Phillips College Accountability Report January 2016 Accountability System, January 2016 1 of 22 Participation - Key Measures Enrollment 1. Fall Headcount (Unduplicated) Fall 2000 Fall 2014 Fall 2015

More information

Sunnyvale Middle School School Accountability Report Card Reported Using Data from the School Year Published During

Sunnyvale Middle School School Accountability Report Card Reported Using Data from the School Year Published During Sunnyvale Middle School School Accountability Report Card Reported Using Data from the 2014-15 School Year Published During 2015-16 By February 1 of each year, every school in California is required by

More information

ILLINOIS DISTRICT REPORT CARD

ILLINOIS DISTRICT REPORT CARD -6-525-2- HAZEL CREST SD 52-5 HAZEL CREST SD 52-5 HAZEL CREST, ILLINOIS and federal laws require public school districts to release report cards to the public each year. 2 7 ILLINOIS DISTRICT REPORT CARD

More information

Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Enrollment Forms Packet (EFP) Based on r student(s) grade and applicable circumstances, complete one enrollment package and review the information below to determine what should submit for each student

More information

John F. Kennedy Middle School

John F. Kennedy Middle School John F. Kennedy Middle School CUPERTINO UNION SCHOOL DISTRICT Steven Hamm, Principal hamm_steven@cusdk8.org School Address: 821 Bubb Rd. Cupertino, CA 95014-4938 (408) 253-1525 CDS Code: 43-69419-6046890

More information

ILLINOIS DISTRICT REPORT CARD

ILLINOIS DISTRICT REPORT CARD -6-525-2- Hazel Crest SD 52-5 Hazel Crest SD 52-5 Hazel Crest, ILLINOIS 2 8 ILLINOIS DISTRICT REPORT CARD and federal laws require public school districts to release report cards to the public each year.

More information

Application for Postgraduate Studies (Research)

Application for Postgraduate Studies (Research) Application for Postgraduate Studies (Research) Please complete clearly. This form will be photocopied. Applicant Number (for office use only). For office use only: Admissions Office Admissions Tutor Interview

More information

Interview Contact Information Please complete the following to be used to contact you to schedule your child s interview.

Interview Contact Information Please complete the following to be used to contact you to schedule your child s interview. Cabarrus\Kannapolis Early College High School Interview Contact Information Please complete the following to be used to contact you to schedule your child s interview. Student Name Student Number Middle

More information

Cy-Fair College Teacher Preparation and Certification Program Application Form

Cy-Fair College Teacher Preparation and Certification Program Application Form Cy-Fair College Teacher Preparation and Certification Program Application Form Date Name (circle one) Mr. Mrs. Ms. Miss. (Last, First, Middle) Address (Number, Street, Apartment Number) (City, State, Zip)

More information

Placentia-Yorba Linda Unified School District 1301 E. Orangethorpe Ave., Placentia, CA (714)

Placentia-Yorba Linda Unified School District 1301 E. Orangethorpe Ave., Placentia, CA (714) 1 INTERNATIONAL STUDENTS Welcome to the. This information is for international students who are seeking a one year public high school experience for Grades 9-12. Esperanza High School (www.esperanzahs.net),

More information

Transportation Equity Analysis

Transportation Equity Analysis 2015-16 Transportation Equity Analysis Each year the Seattle Public Schools updates the Transportation Service Standards and bus walk zone boundaries for use in the upcoming school year. For the 2014-15

More information

Raw Data Files Instructions

Raw Data Files Instructions Raw Data Files Instructions Colleges will report the above information for students in the Main Cohort for each of the reporting timeframes and the system will calculate the sub cohorts and metrics based

More information

. Town of birth. Nationality. address)

. Town of birth. Nationality. address) ACTING BA (HONS) IN ACTING / FOUNDATION COURSE IN ACTING APPLICATION FOR ENTRY IN SEPTEMBER 2018 PLEASE COMPLETE ALL SECTIONS OF THIS APPLICATION FORM AND RETURN IT WITH THE REGISTRATION FEE Please tick

More information

11 CONTINUING EDUCATION

11 CONTINUING EDUCATION 1 of 5 3/13/2013 3:56 PM Chapter Cos 11 CONTINUING EDUCATION Cos 11.01 Authority and purpose. Cos 11.02 Definitions. Cos 11.03 Continuing education requirements for license renewal. Cos 11.04 Standards

More information

Coming in. Coming in. Coming in

Coming in. Coming in. Coming in 212-213 Report Card for Glenville High School SCHOOL DISTRICT District results under review by the Ohio Department of Education based upon 211 findings by the Auditor of State. Achievement This grade combines

More information

TRANSFER APPLICATION: Sophomore Junior Senior

TRANSFER APPLICATION: Sophomore Junior Senior : Sophomore Junior Senior 2714 W Augusta Phone: 773.534.9718 Fax: 773.534.4022 Email: admissions@chiarts.org Web: www.chiarts.org CPS Mail Run: G.S.R. #35 FRESHMAN APPLICATION STEPS Thank you for your

More information

ESL Summer Camp: June 18 July 27, 2012 Homestay Application (Please answer all questions completely)

ESL Summer Camp: June 18 July 27, 2012 Homestay Application (Please answer all questions completely) ESL Summer Camp: June 18 July 27, 2012 Homestay Application (Please answer all questions completely) Family Name (Surname) First Name (Given name) Applicant s Complete Address Male: Female: REGISTRATION

More information

CLINICAL TRAINING AGREEMENT

CLINICAL TRAINING AGREEMENT CLINICAL TRAINING AGREEMENT This Clinical Training Agreement (the "Agreement") is entered into this 151 day of February 2009 by and between the University of Utah, a body corporate and politic of the State

More information

PUBLIC INFORMATION POLICY

PUBLIC INFORMATION POLICY CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA Landscape Architecture College of Environmental Design PUBLIC INFORMATION POLICY Landscape Architecture Accreditation Board (LAAB) accredited programs are

More information

Application for Admission

Application for Admission Application for Admission Princeton University The Graduate School Exchange/Visiting Student Scholar Program (nondegree) UPON COMPLETION, PLEASE SEND TO THE GRADUATE ADMISSIONS OFFICE ONE CLIO HALL PRINCETON,

More information

Department of Social Work Master of Social Work Program

Department of Social Work Master of Social Work Program Dear Interested Applicant, Thank you for your interest in the California State University, Dominguez Hills Master of Social Work (MSW) Program. On behalf of the faculty I want you to know that we are very

More information

Psychometric Research Brief Office of Shared Accountability

Psychometric Research Brief Office of Shared Accountability August 2012 Psychometric Research Brief Office of Shared Accountability Linking Measures of Academic Progress in Mathematics and Maryland School Assessment in Mathematics Huafang Zhao, Ph.D. This brief

More information

MANDATORY CONTINUING LEGAL EDUCATION REGULATIONS PURPOSE

MANDATORY CONTINUING LEGAL EDUCATION REGULATIONS PURPOSE MANDATORY CONTINUING LEGAL EDUCATION REGULATIONS PURPOSE The Virginia Supreme Court has established, by Rule of Court, a mandatory continuing legal education program in the Commonwealth of Virginia, which

More information

Missouri 4-H University of Missouri 4-H Center for Youth Development

Missouri 4-H University of Missouri 4-H Center for Youth Development Missouri 4-H University of Missouri 4-H Center for Youth Development Missouri 4-H Key Award Purpose To Encourage: A quality educational programs for all members. A safe environment where all youth feel

More information

SAMPLE AFFILIATION AGREEMENT

SAMPLE AFFILIATION AGREEMENT SAMPLE AFFILIATION AGREEMENT AFFILIATION AGREEMENT FOR USE WITH A FOREIGN STUDY PROGRAM W I T N E S S E T H and WHEREAS, cordial relations exist between the United Stated of America and France; WHEREAS,

More information

https://secure.aacte.org/apps/peds/print_all_forms.php?view=report&prin...

https://secure.aacte.org/apps/peds/print_all_forms.php?view=report&prin... 1 of 35 4/25/2012 9:56 AM A» 2011 PEDS» Institutional Data inst id: 3510 Institutional Data A_1 Institutional Information This information will be used in all official references to your institution. Institution

More information

Effective Recruitment and Retention Strategies for Underrepresented Minority Students: Perspectives from Dental Students

Effective Recruitment and Retention Strategies for Underrepresented Minority Students: Perspectives from Dental Students Critical Issues in Dental Education Effective Recruitment and Retention Strategies for Underrepresented Minority Students: Perspectives from Dental Students Naty Lopez, Ph.D.; Rose Wadenya, D.M.D., M.S.;

More information

Data Glossary. Summa Cum Laude: the top 2% of each college's distribution of cumulative GPAs for the graduating cohort. Academic Honors (Latin Honors)

Data Glossary. Summa Cum Laude: the top 2% of each college's distribution of cumulative GPAs for the graduating cohort. Academic Honors (Latin Honors) Institutional Research and Assessment Data Glossary This document is a collection of terms and variable definitions commonly used in the universities reports. The definitions were compiled from various

More information

Cypress College STEM² Program Application

Cypress College STEM² Program Application Academic Year 2016 2017 ********************************************************************************* INSTRUCTIONS Complete this application thoroughly and submit ONLINE OR IN PERSON. Make sure to

More information

Application for Fellowship Leave

Application for Fellowship Leave PDF Fill-In Form: Type On-Screen, then Print for Signatures and Chair Approvals Brooklyn College (2018-2019 Academic Year) Application for Fellowship Leave Instructions for Applicant: Please complete Sections

More information

Bethune-Cookman University

Bethune-Cookman University Bethune-Cookman University The Independent Colleges and Universities of Florida Community College Articulation Manual 2012-2013 1 BETHUNE-COOKMAN UNIVERSITY ICUF ARTICULATION MANUAL GENERAL ADMISSION PROCEDURES

More information

HIGH SCHOOL PREP PROGRAM APPLICATION For students currently in 7th grade

HIGH SCHOOL PREP PROGRAM APPLICATION For students currently in 7th grade HIGH SCHOOL PREP PROGRAM APPLICATION For students currently in 7th grade APPLICATION CHECKLIST: Applications can be mailed, faxed, or dropped off to the address below. Proof of Income (Household income

More information

This survey is intended for Pitt Public Health graduates from December 2013, April 2014, June 2014, and August EOH: MPH. EOH: PhD.

This survey is intended for Pitt Public Health graduates from December 2013, April 2014, June 2014, and August EOH: MPH. EOH: PhD. Pitt Public Health Exit Survey This survey will ask you questions about your program and the services provided by the Office of Student Affairs, as well as your overall assessment of the Graduate School

More information

Anyone with questions is encouraged to contact Athletic Director, Bill Cairns; Phone him at or

Anyone with questions is encouraged to contact Athletic Director, Bill Cairns; Phone him at or SKYLINE GRIZZLIES ATHLETIC REQUIREMENTS and REGISTRATION FORMS 2017-18 According to School District #91 and Idaho High School Activities Association rules, all students interested in participating in athletics

More information

International Undergraduate Application for Admission

International Undergraduate Application for Admission CHECKLIST Application fee: US$30 (required) Completed application form Request academic records International Undergraduate Application for Admission Request exam score reports Copy of passport Completed

More information

Cooper Upper Elementary School

Cooper Upper Elementary School LIVONIA PUBLIC SCHOOLS www.livoniapublicschools.org/cooper 213-214 BOARD OF EDUCATION 213-14 Mark Johnson, President Colleen Burton, Vice President Dianne Laura, Secretary Tammy Bonifield, Trustee Dan

More information

INTER-DISTRICT OPEN ENROLLMENT

INTER-DISTRICT OPEN ENROLLMENT Effective 2015-2016 school year only INTER-DISTRICT OPEN ENROLLMENT The Kenston Board of Education shall permit the enrollment of students from any Ohio district in a school or program in this district,

More information

Verification Program Health Authority Abu Dhabi

Verification Program Health Authority Abu Dhabi ONLY COMPLETE FORMS WILL BE ACCEPTED Verification Program Health Authority Abu Dhabi Facility Name (If applicable) PearsonVue Registration ID (if applicable) Personal Details: Please give your name in

More information

INSTRUCTIONS FOR COMPLETING THE EAST-WEST CENTER DEGREE FELLOWSHIP APPLICATION FORM

INSTRUCTIONS FOR COMPLETING THE EAST-WEST CENTER DEGREE FELLOWSHIP APPLICATION FORM INSTRUCTIONS FOR COMPLETING THE EAST-WEST CENTER DEGREE FELLOWSHIP APPLICATION FORM Biographical Data are collected as part of record-keeping requirements and have no bearing on the selection process.

More information

Thomas Jefferson University Hospital. Institutional Policies and Procedures For Graduate Medical Education Programs

Thomas Jefferson University Hospital. Institutional Policies and Procedures For Graduate Medical Education Programs Thomas Jefferson University Hospital Institutional Policies and Procedures For Graduate Medical Education Programs Table of Contents Dispute Resolution Procedure 1 Duty Hours 2 Duty Hours Requests for

More information

ALL DOCUMENTS MUST BE MAILED/SUBMITTED TOGETHER

ALL DOCUMENTS MUST BE MAILED/SUBMITTED TOGETHER LOUISIANA BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY 37283 SWAMP ROAD, SUITE 3B PRAIRIEVILLE, LOUISIANA 70769 PHONE: (225) 313-6358 or (800) 246-6050 WWW.LBESPA.ORG licensure renewal

More information

Educational Attainment

Educational Attainment A Demographic and Socio-Economic Profile of Allen County, Indiana based on the 2010 Census and the American Community Survey Educational Attainment A Review of Census Data Related to the Educational Attainment

More information

Basic Skills Initiative Project Proposal Date Submitted: March 14, Budget Control Number: (if project is continuing)

Basic Skills Initiative Project Proposal Date Submitted: March 14, Budget Control Number: (if project is continuing) Basic Skills Initiative Project Proposal 2016-2017 Date Submitted: March 14, 2016 Check One: New Proposal: Continuing Project: X Budget Control Number: (if project is continuing) Control # 87-413 - EOPS

More information

Wisconsin 4 th Grade Reading Results on the 2015 National Assessment of Educational Progress (NAEP)

Wisconsin 4 th Grade Reading Results on the 2015 National Assessment of Educational Progress (NAEP) Wisconsin 4 th Grade Reading Results on the 2015 National Assessment of Educational Progress (NAEP) Main takeaways from the 2015 NAEP 4 th grade reading exam: Wisconsin scores have been statistically flat

More information

NATIVE VILLAGE OF BARROW WORKFORCE DEVLEOPMENT DEPARTMENT HIGHER EDUCATION AND ADULT VOCATIONAL TRAINING FINANCIAL ASSISTANCE APPLICATION

NATIVE VILLAGE OF BARROW WORKFORCE DEVLEOPMENT DEPARTMENT HIGHER EDUCATION AND ADULT VOCATIONAL TRAINING FINANCIAL ASSISTANCE APPLICATION NATIVE VILLAGE OF BARROW WORKFORCE DEVLEOPMENT DEPARTMENT HIGHER EDUCATION AND ADULT VOCATIONAL TRAINING FINANCIAL ASSISTANCE APPLICATION To better assist our Clients, here is a check off list of the following

More information

Vocational Training. Pre-Application

Vocational Training. Pre-Application Vocational Training Pre-Application 1 Vocational Training Application Checklist Dear Prospective Student: Congratulation on your choice to continue your education at an institute of Higher learning! Unfortunately,

More information

ACHE DATA ELEMENT DICTIONARY as of October 6, 1998

ACHE DATA ELEMENT DICTIONARY as of October 6, 1998 ACHE DATA ELEMENT DICTIONARY as of October 6, 1998 Element Title: Reference Numbers: Institution FICE Code FICE ST010, GR010 The identification number for each reporting institution will be the institution's

More information

North Carolina Community Colleges Golden LEAF Scholars Program Two-Year Colleges Student Application

North Carolina Community Colleges Golden LEAF Scholars Program Two-Year Colleges Student Application North Carolina Community Colleges Golden LEAF Scholars Program Two-Year Colleges Student Application Instructions: Complete this application and return the completed application to the college s Financial

More information

Organization Profile

Organization Profile Preview Form This is an example of the application questions with which you will be presented. It is recommended that you compose the answers to the paragraph questions in a word processing program and

More information

WASHINGTON STATE. held other states certificates) 4020B Character and Fitness Supplement (4 pages)

WASHINGTON STATE. held other states certificates) 4020B Character and Fitness Supplement (4 pages) WASHINGTON STATE TEACHER RENEWAL AND CONTINUING CERTIFICATION WAC 181-79A-250 APPLICATION INSTRUCTIONS (For more information visit our certification website at http://www.k12.wa.us/certification/) Attention:

More information

THE LUCILLE HARRISON CHARITABLE TRUST SCHOLARSHIP APPLICATION. Name (Last) (First) (Middle) 3. County State Zip Telephone

THE LUCILLE HARRISON CHARITABLE TRUST SCHOLARSHIP APPLICATION. Name (Last) (First) (Middle) 3. County State Zip Telephone THE LUCILLE HARRISON CHARITABLE TRUST SCHOLARSHIP APPLICATION 1. Name (Last) (First) (Middle) 2. Street City 3. County State Zip Telephone 4. Are you a permanent resident of Harrison County? 5. M F SSN

More information

ESIC Advt. No. 06/2017, dated WALK IN INTERVIEW ON

ESIC Advt. No. 06/2017, dated WALK IN INTERVIEW ON EMPLOYEES STATE INSURANCE CORPORATION ESIC-PGIMSR & ESIC MEDICAL COLLEGE ESIC Hospital & ODC (EZ) Diamond Harbour Road, P.O. Joka, Kolkata - 700104 Tel No: (033) 24381382, Tel/Fax No: (033) 24381176 E-mail:

More information

MSW Application Packet

MSW Application Packet Stephen F. Austin State University Master of Social Work Program Accredited by: The Council on Social Work Education MSW Application Packet P. O. Box 6104, SFA Station 420 East Starr Avenue Nacogdoches,

More information

Hokulani Elementary School

Hokulani Elementary School Hokulani Elementary Code: 109 Status and Improvement Report Year -11 Contents Focus On Standards Grades K-5 This Status and Improvement Report has been prepared as part of the Department's education accountability

More information

Supply and Demand of Instructional School Personnel

Supply and Demand of Instructional School Personnel Supply and Demand of Instructional School Personnel Presentation to the 82 nd Annual Virginia Middle and High School Principals Conference and Exposition Mrs. Patty S. Pitts Assistant Superintendent of

More information

Grant/Scholarship General Criteria CRITERIA TO APPLY FOR AN AESF GRANT/SCHOLARSHIP

Grant/Scholarship General Criteria CRITERIA TO APPLY FOR AN AESF GRANT/SCHOLARSHIP 2017-2018 Grant/Scholarship General Criteria CRITERIA TO APPLY FOR AN AESF GRANT/SCHOLARSHIP 1) Student(s) must attend an AESF member Episcopal school 2) An AESF Grant/Scholarship Application and supporting

More information

The Demographic Wave: Rethinking Hispanic AP Trends

The Demographic Wave: Rethinking Hispanic AP Trends The Demographic Wave: Rethinking Hispanic AP Trends Kelcey Edwards & Ellen Sawtell AP Annual Conference, Las Vegas, NV July 19, 2013 Exploring the Data Hispanic/Latino US public school graduates The Demographic

More information

CERTIFIED TEACHER LICENSURE PROFESSIONAL DEVELOPMENT PLAN

CERTIFIED TEACHER LICENSURE PROFESSIONAL DEVELOPMENT PLAN CERTIFIED TEACHER LICENSURE PROFESSIONAL DEVELOPMENT PLAN 2016-2017 DODGE CITY PUBLIC SCHOOLS USD 443 DODGE CITY, KANSAS LOCAL PROFESSIONAL DEVELOPMENT GUIDE Table of Contents 1. General Information -

More information

Northwest Georgia RESA

Northwest Georgia RESA Northwest Georgia RESA Office of Executive Director 3167 Cedartown Hwy SE Rome, GA 30161 (706) 295-6189 Fax: (706) 295-6098 Date of Application: Date Available for Employment: Personal Information Full

More information

DLM NYSED Enrollment File Layout for NYSAA

DLM NYSED Enrollment File Layout for NYSAA Enrollment Field Definitions AYP_School_ Identifier Alphanumeric; 30 No The BEDSCODE of the DISTRICT that has Committee on Special Education (CSE) responsibility for the student. Must include any leading

More information

Adult Vocational Training Tribal College Fund Gaming

Adult Vocational Training Tribal College Fund Gaming Statement of Goals and Objectives Adult Vocational Training Tribal College Fund Gaming The Kaibab Band of Paiute Indians has instituted a long range goal of economic self-sufficiency and social development

More information

Effective practices of peer mentors in an undergraduate writing intensive course

Effective practices of peer mentors in an undergraduate writing intensive course Effective practices of peer mentors in an undergraduate writing intensive course April G. Douglass and Dennie L. Smith * Department of Teaching, Learning, and Culture, Texas A&M University This article

More information

Demographic Survey for Focus and Discussion Groups

Demographic Survey for Focus and Discussion Groups Appendix F Demographic Survey for Focus and Discussion Groups Demographic Survey--Lesbian, Gay, and Bisexual Discussion Group Demographic Survey Faculty with Disabilities Discussion Group Demographic Survey

More information