PERSONAL INFORMATION APPLICATION FOR ADMISSION 12-month Advanced Placement in Pediatric Dentistry for Internationally-Educated Pediatric Dentists Applying for Fall 20 First Name MI Last Name Preferred Name CURRENT ADDRESS Address Apt/Unit # City State Zip Code Nation (if not USA) PERMANENT ADDRESS Address Apt/Unit # City State Zip Code Nation (if not USA) CONTACT INFORMATION Home Phone Number Permanent Phone Number (Day) Work/School Phone Number Permanent Phone Number (Night) Email PERSONAL INFORMATION Date of Birth (MM/DD/YY) Gender DENTPIN CITIZENSHIP INFORMATION City of Birth State of Birth Nation of Birth Nation of Citizenship Are you a bona fide Florida resident? Yes No If yes, how many years? Non-US Citizens only: Are you a permanent resident alien? If yes, please attach a copy of both sides of your permanent resident alien card. If no, what is your citizenship or visa status? 1
ETHNICITY Do you consider yourself to be of Hispanic origin? I am NOT Spanish/Hispanic/Latino/Latina Yes, I am Spanish/Hispanic/Latino/Latina If yes, please check all that apply: Cuban Mexican, Mexican American, Chicano, Chicana Puerto Rican South or Central American Other Spanish culture or origin If other, please specify RACE: Which of the following best describes your race? Please check all that apply. Asian Asian Indian Cambodian Chinese Filipino Japanese White Korean Malaysian Pakistani Vietnamese Other Asian If other, please specify Black or African American American Indian/Alaskan Native Please specify the name of your tribe Native Hawaiian Guamanian or Charmorro Samoan Other Pacific Islander If other, please specify UNDERGRADUATE EDUCATION Institution 1 Institution 2 Dates of Attendance (mm/yy): From: To: Dates of Attendance (mm/yy): From: To: Date (mm/yy) Date (mm/yy) 2
PROFESSIONAL AND GRADUATE EDUCATION AND ADVANCED SPECIALTY TRAINING Institution 1 Institution 2 Dates of Attendance (mm/yy): From: To: Dates of Attendance (mm/yy): From: To: Date (mm/yy) Date (mm/yy) RESEARCH EXPERIENCE List any scientific or clinical publications or presentations you have given at scientific meetings or dental societies. Institution include city, state, and country Research/Subject From (mm/yy) To(mm/yy) 3
DENTAL EXPERIENCE: List any academic distinctions, fellowships, scholarships, awards or prizes you obtained in college, dental school, etc. List states in which you are licensed to practice dentistry, or another profession & license # List location and dates that you have been engaged in the private practice of dentistry. Institution include city, state, and country From (mm/yy) To (mm/yy) 1. Have you ever been denied state licensure? Yes No 2. If state licensed, during your course of licensure, have your privileges ever been modified, suspended, or revoked? Yes No If yes to either question 1 or 2, attach a separate sheet of paper explaining these circumstances. 3. Have you ever had any dental malpractice proceedings brought against you? Yes No If yes, attach appropriate documentation which includes charges, outcome and/or pending information. 4
4. Have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any education institution? Yes No 5. Have you ever been charged with a violation of the law which resulted in probation, community service, a jail sentence, or the revocation or suspension of your driver s license (including traffic violations which resulted in a fine of $200 of more)? Yes No If yes to either question 4 or 5, please include a full statement of the relevant facts with this application. List record of military service. (Indicate service/branch, rank, and dates.) Personal Essay: Briefly state below your reasons for seeking advanced education in Pediatric Dentistry and any additional information regarding your past experiences and qualifications. (A separate sheet(s) may be attached if you prefer.) 5
I hereby certify that all statements made in connection with this application are true and correct. I understand that failure to supply complete and correct information will result in rejection of my application, or dismissal from the program if falsification is discovered. Furthermore, I hereby give my permission to the University of Florida College of Dentistry to release any information regarding my admission credentials to those agencies the school authorizes as appropriate. Signature Date Email Completed Application to: GradAdmissions@dental.ufl.edu OR Mail Completed Application to: Dr. Pamela Sandow University of Florida College of Dentistry Office of Admissions PO Box 100402 Gainesville, FL, 32610 6