Residency/Postgraduate Training Program Supplemental Application



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2013/14 Residency/Postgraduate Training Program


Supplemental Application


Please select the program to which you are applying:



Advanced Education in General Dentistry – Westwood



Oral and Maxillofacial Radiology



Advanced Education in General Dentistry (International slot)



Orofacial Pain and Dysfunction



Advanced Prosthodontics



Orofacial Pain and Dysfunction (International slot)



Endodontics



Orthodontics



Endodontics (International slot)



Orthodontics (International slot)



General Practice Residency







Section I: Personal & Contact Information


Name (first, middle, last):      

Mailing Address:      

Permanent Address:      

Day Telephone: (     )       Evening Telephone: (     )      

Email Address:       Fax Number: (     )      

Date of Birth:       Place of Birth:      

Gender:       Marital Status (0ptional)      

Last 4 Digits of Soc. Sec #:      If non-US Citizen, current immigration/visa status:      

Ethnicity (optional): Please Indicate in which of the following classifications you consider yourself.


Decline to State

American Indian/Alaskan

Black/African-American

Chicano/Mexican-American

Chinese/Chinese-American

East Indian/Pakistani



Filipino/Filipino-American

Japanese/Japanese American

Korean/Korean-American

Latino/Other Spanish American

Other Asian (not including Middle Eastern)

Pacific Islander (including Polynesian, Micronesian and other Pacific Islander)



White/Caucasian (including Middle Eastern)



Section II: Education, Discipline & Licensure Information
Give names of all community colleges, universities, graduate, postgraduate, professional schools, and hospitals at which credit has been received.





DATES ATTENDED




CERTIFICATES

INSTITUTION

FROM

TO

MAJOR AND MINOR FIELDS

DEGREE AND DATE

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Are you currently under investigation for or have you ever been subject to a disciplinary action at any college, university, dental school or other training program in connection with misconduct or violation of an honor code which investigation could have resulted or did result in disqualification, suspension, dismissal or other sanctions? Yes No

If yes, please explain:      

If yes, I authorize you to contact the Dean of Students at       (specify institution) for further details about this incident.


Have you withdrawn from or been dismissed by a Postdoctoral or Graduate Program in Dentistry? Yes No

If yes, please give a brief description of circumstances:      


Please describe your dental licensure status, including any states or countries in which you have been license:      
Please disclose and explain any suspensions, restrictions or revocations on your ability to practice dentistry in any jurisdiction:      
Have you ever been convicted or plead no contest to any offense, misdemeanor, or felony in any state, the United States, or a foreign country (excluding violations in traffic laws resulting in fines of $200 or less)? Yes No

If yes, please explain.      

Section III: Experience1







DATES



TYPE*

INSTITUTION OR ORGANIZATION

FROM

TO

NATURE OF WORK

C

R

T

     

     

     

     

C

R

T

     

     

     

     

C

R

T

     

     

     

     

C

R

T

     

     

     

     

C

R

T

     

     

     

     

C

R

T

     

     

     

     

*Type of Experience: C=Clinical; R=Research; T= Teaching

Section IV: Personal Statement

Insert below, a statement describing your general interests. Include (a) your reasons for seeking advanced training and education in this subject, (b) your career goals as to your plans for practice, research, teaching, community health programs, etc., (c) the type of program you feel would best suit your needs (i.e., university and/or hospital), and (d) any additional information you feel pertinent.
     

Applicants who fail to submit all necessary documents for consideration may be excluded from the admissions process. It is the responsibility of the applicant to insure that all pertinent records have been received by the Office of Admissions.


I understand that it is my responsibility to ensure that all pertinent records have been submitted to and received by the UCLA School of Dentistry Office of Admissions and further that if I fail to submit all necessary documents for consideration, I may be excluded from the admissions review process. By signing below, I am confirming that all of the statements made by me in this form are complete, true and accurate to the best of my knowledge. I understand that falsification of any of the information contained in my admissions credentials including this form may subject me to elimination from any further consideration by the admissions committee and/or dismissal from the Residency Program.

____________________________________________________ ______________________________________________

      (Type name in field and sign on line) (Insert date on line)

Residency/Postgraduate Training Program Application Checklist:




    • Timely application to PASS (if applicable)




    • Timely submission of Supplemental Application packet which consists of:

  1. this supplemental application

  2. official undergraduate school transcripts

  3. updated CV

Please send all materials to:


Postgraduate Program Admissions

__________________ Program

UCLA School of Dentistry

Office of Student Affairs

10833 Le Conte Avenue, Room A0-111 CHS

Los Angeles, CA 90095-1668




1 Please type your experience in rather than referring us to a CV.

___________ (initials) Page

05302013



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