University of Rochester Medical Center



15872791061499Paste Picture Here00Paste Picture HereUniversity of RochesterUniversity of Rochester Medical Center-1104903810Application Date__________ _________ _________ Month Day Year020000Application Date__________ _________ _________ Month Day YearEastman Institute for Oral Health625 Elmwood AvenueRochester, New York 14620-2989 USA(585) 275-8315APPLICATIONINTERNATIONAL POSTDOCTORAL DENTAL TRAINING PROGRAMSPLEASE READ BEFORE CONTINUING: International Postdoctoral Dental Training Programs are available to applicants who obtained their dental degree outside the United States in a non-accredited American Dental Association’s (ADA) Commission on Dental Accreditation (CODA) dental school.DIRECTIONS:A $195.00 non-refundable application fee is required at the time of application in order for your application to be reviewed and/or considered. This fee can only be paid by credit card via the following link – . The fee is non-refundable and is not credited toward any charges when an accepted applicant registers.If applying for more than one (1) program a separate, completed application must be submitted for each and an application fee is required for each application.Please pay special attention to the way in which you can apply for an International Postdoctoral Dental Training Program as applications received any other way will not be considered. This application is to be used for any educational program that has a “Yes” in the “EIOH” column.Please place a Checkmark () next to the Program(s) for which you are applying.Please refer to the “Prospective Applicant Letter” for additional information (application deadline dates, requirements, estimated costs, etc.)Previously Applied?YESNOIf yes, please indicate Year:*Program Name:*if before 2014 all required documents as outlined in the Prospective Applicant Letter and Checklist will need to be submitted. If 2014 your file will be pulled for review.APPLICATION INFORMATIONPASSMatchEIOHApplication Deadline(of year preceding start of program)Interview Dates(of year preceding start of program)Decision/Notification Dates(after interview)Two-Year Training Program in Advanced Education in General Dentistry (AEGD)NoNoYesSeptember 1stSeptember/October/NovemberJanuaryOrofacial Pain (formerly TMJD)NoNoYesAugust 1stSeptember/OctoberNovemberOrthodontics & Dentofacial OrthopedicsNoNoYesAugust 1stSeptember/OctoberNovemberPeriodontologyNoNoYesAugust 1stAugustSeptemberProsthodonticsYes (Code 416)NoYesAugust 1stAugustSeptemberDate of BirthPlace of BirthMonthDayYearCityState, Zip CodeCountryPermanent AddressPresent Address, if different than Permanent AND Email AddressStreet AddressStreet AddressCity State, Zip Code CountryCity State, Zip Code CountryPhone # - Please provide the best number to callEmail AddressDemographics:Citizenship Status:US CitizenYesNoPermanent ResidentYesNoOtherYesIf “Other” please provide County of Citizenship:Visa sponsorship needed?YesNoIf Yes:Are you currently in the US on a visa?YesNoIf Yes, please provide the following:Visa TypeCurrent End DateMM/DD/YYYYNative Language: _____________________________________________________Please note: Applicants whose native language is not English are required to take the TOEFL. Official TOEFL scores must be submitted at the time of application. No minimum score is currently required.Gender:MaleFemaleSocial Security Number:YesNoEducation and Professional Information:Dental Boards (if applicable). National Board scores must be sent directly to EIOH from the ADA Joint Commission of National Dental Examinations. Board scores will not be accepted if submitted by the applicant.State(s)Score, Part IScore, Part IILicensure: Please list all licenses ever held to practice dentistry (if any).State/JurisdictionNumberDate IssuedExpiration DateUndergraduate EducationUndergraduate College(s)Dates AttendedMajorDegree (if any)Grade Point AverageClass StandingFromToNameCity State/CountryNameCity State/CountryNameCity State/CountryGraduate EducationDental & Graduate School(s)Dates AttendedMajorDegree (if any)Grade Point AverageClass StandingFromToNameCity State/CountryNameCity State/CountryNameCity State/CountryEducation and Professional Information (continued):Postgraduate EducationPostgraduate School(s)Dates AttendedMajorDegree (if any)FromToNameCity State/CountryNameCity State/CountryPostgraduate Experience ~ Appointments held, Courses, Practice, Military ExperienceActivityLocation/PlaceDatesToFromEducation and Professional Information (continued):Additional Experience/Activities since graduating from dental school (if applicable):Patient Care:Practice Location: _______________________________________________________________________________________________Employer: ______________________________________________________________________________________________________Type of Practice: ________________________________________________________________________________________________Dates: _________________________________________________________________________________________________________Teaching:Institution: _____________________________________________________________________________________________________Department/Area of Teaching: _____________________________________________________________________________________Immediate Supervisor: ____________________________________________________________________________________________Faculty Rank: ___________________________________________________________________________________________________Dates: _________________________________________________________________________________________________________Research:Institution: _____________________________________________________________________________________________________Department/Area of Research: ______________________________________________________________________________________Immediate Supervisor: ____________________________________________________________________________________________Position Held: __________________________________________________________________________________________________Dates: _________________________________________________________________________________________________________Other:Activity: _______________________________________________________________________________________________________Location: ______________________________________________________________________________________________________Employer: ______________________________________________________________________________________________________Dates: _________________________________________________________________________________________________________The top three (3) fields of dentistry you are most interested in (by using numerals - 1, 2, 3)…EndodonticsPreventive DentistryRestorative DentistryDental Public HealthDental School TeachingScientific ResearchOther (specify)For each of the following please provide concise statements: Professional Goals:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reasons for applying to this program:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List or describe any additional information concerning your application that you wish to have considered by the Admission’s Committee:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If you are applying for similar training in other schools or institutions, please list them here.School or InstitutionCity and StateLETTERS OF RECOMMENDATIONNEW REQUIREMENT – References must be provided electronically via the following link - . Hard copy references will no longer be accepted. In order to complete this requirement, via the link provided above, you will need to have the following information available for each referee: names, email addresses and phone #s for three (3) referees, one of which must be the dean of your dental school; two (2) must be members of your dental school faculty or other supervisory personnel who have had sufficient contact with you to judge your personal and professional qualifications.University of RochesterUniversity of Rochester Medical CenterEastman Institute for Oral Health625 Elmwood AvenueRochester, New York 14620-2989 USA(585) 275-8315CERTIFICATION STATEMENTI certify that the information presented in my application is accurate, complete and honestly presented. I also certify that any information submitted on my behalf, including letters of recommendation are authentic. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the withdrawal of any offer of admission, or for discipline, dismissal or revocation of certificate if discovered at a later date.I also, understand that final acceptance is contingent upon satisfactory completion of academic work, submission of transcript(s), Dean’s letter.___________________________________________________Name (printed)____________________________________________________Signature____________________________________________________Date ................
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