From Practice to Preceptor Program (FP2P) Application for Admission Personal Data Name Permanent Address Mailing Address (if different from above) County Telephone Number Email 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)
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.
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
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?
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 Email 1. 2. 3. 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