Rutgers, The State University Of New Jersey
School Of Dental Medicine
Graduate Dental Education Programs
Application For Admissions
Page | 1
RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY
SCHOOL OF DENTAL MEDICINE
POSTGRADUATE PROGRAMS
APPLICATION FOR ADMISSIONS
Please Read All Instructions Carefully Before Completing This Form
Please Complete All Information
This Application is for the Graduate Dental Educational Program in: (Check One)
PERIODONTICS
Personal Data
Name
Social Security Number
Permanent Address
Telephone Number
If New Jersey Resident, how long?
County?
Mailing Address (if different from above)
Cell Number
Email
Citizenship:
US Citizen
Permanent
Foreign
If foreign national, current visa status:
Country of birth:
Responses to these questions are voluntary and will be kept confidential. Failure to furnish this information will not adversely
affect the status of your application.
Date of Birth:
mm/dd/yyyy
Male
Female
Race:
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
(check all that apply)
Ethnicity:
Hispanic Yes No
General Education
List all post-secondary schools attended, including dates of attendance and degree(s) received.
Post-Secondary School Dates of Attendance Major Degree(s) & Date Received
1.
2.
3.
Rutgers, The State University Of New Jersey
School Of Dental Medicine
Graduate Dental Education Programs
Application For Admissions
Page | 2
Professional Education
List all professional schools attended, including dates of attendance and degree(s) received.
Professional School Dates of Attendance Class Standing GPA
Degree(s) & Date Received
1.
2.
3.
Professional Experience(s)
List all graduate dental educational courses, internships and/or residencies.
School or Hospital Dates of Attendance Course, Residency, Internship Certificate(s)/Degree(s) & Date Received
1.
2.
3.
List any academic distinctions, fellowships, scholarships, awards or prizes obtained.
List any research or teaching experience.
List any scientific or clinical publications, abstracts or presentations at scientific or dental society meetings. Provide any available reprints.
List all states in which you have a license to practice dentistry.
List any private practice or other dental related employment experience subsequent to completing dental school.
Location Type of Practice/Employment Full or Part Time Dates Associate’s Name, if applicable
Location
Type if Practice/Employment
Full/Part Time
Dates
Associate’s Name, If Applicable
Please read and understand the statement of essential function
http://sdm.rutgers.edu/CDE/FP2P_EssentialFunctions_Appl.pdf which all students must satisfy for the program of study to which I am applying, with or
without reasonable accommodation. I acknowledge that the UMDNJ-NJDS has established these requirements for successful academic progress toward the
degree/certificate sought. If I require accommodation, I will do so promptly in writing.
RSMD is committed to complying with the requirements of the Americans with Disabilities Act.
Were you ever subject to any disciplinary action by any college, university, or professional school for unacceptable academic performance (academic
probation, suspension, dismissal) or conduct violations?
(please circle answer) Yes or No. If yes, please explain. _________________________________________________________________________________________________________________
Have you ever been subject to disciplinary action by any professional licensing board?
(please circle answer) Yes or No. If yes, please explain. _________________________________________________________________________________________________________________
Have you ever been charge with or have you ever been convicted of a felony or misdemeanor, other than a minor traffic violation?
(please circle answer) Yes or No. If yes, please explain__________________________________________________________________________________________________________________
Signature of Applicant
Date
Rutgers, The State University Of New Jersey
School Of Dental Medicine
Graduate Dental Education Programs
Application For Admissions
Page | 3
PLEASE INCLUDE A CURRICULUM VITAE
Use this sheet and its reverse to discuss the following:
1. The reasons for your interest in graduate dental education
Rutgers, The State University Of New Jersey
School Of Dental Medicine
Graduate Dental Education Programs
Application For Admissions
Page | 4
2. Your immediate and long-range career plans (in clinical practice, academics, research, etc.)
3. Any research area you wish to investigate during your course of study.
