PROGRAM FOR ADVANCED STANDING STUDENTS 20112012 SUPPLEMENTAL APPLICATION

Please complete the interactive PDF online and print for submission. Applicant must provide full legal name as it appears on his/her passport. If appropriate, please also provide maiden name in order to match application documents. Last Name _________________________________________ First ______________________________________________ Middle __________________ Maiden Name (if applicable) __________________________________________________________ Male Female

CAAPID ID # ____________________________________________________ DENT PIN # ____________________________________________________ Date of birth: Month ______________ Day _______________Year_____________ Place of Birth _____________________________________________ Have you applied to the University of Pennsylvania School of Dental Medicines PASS program before? Yes No

If yes, please indicate the most recent application year ________________________________________________________________________________ Please list your current place of residence if different from mailing address listed on the CAAPID application. Street Address __________________________________________________________________________________________________________________ City ______________________________________________ State ____________________________ Zip or Postal Code __________________________ Country ______________________________________________________________________________________________________________________ LETTERS OF EVALUATION Three letters of evaluation are required. One letter is required from the dean or director of the applicants dental school. The second letter is required from a faculty member from the applicants dental school. The third letter must be submitted from another faculty member, dental professional or work supervisor. Letters should be submitted to the CAAPID Application Service. Letters submitted after August 15, 2011, can be sent directly to the Office of Admissions PASS Program to expedite processing. Please list names and positions of evaluators from whom you have requested letters. Name of Dean/Director of dental school ___________________________________________________________________________________________ Title/Position __________________________________________________________________________________________________ Name of dental school _________________________________________________________________________________________ Name of faculty evaluator _______________________________________________________________________________________________________ Title/Position __________________________________________________________________________________________________ Name of educational institution/location of dental practice ___________________________________________________________ Name of faculty/dental professional/work supervisor _________________________________________________________________________________ Title/Position __________________________________________________________________________________________________ Name of educational institution/location of dental practice/work ______________________________________________________ REAPPLICANTS All reapplicants must submit a CAAPID application, Penn Dental PASS Supplemental Application, essay responses, and application fee. Documents from prior application (transcripts, NBDE Part 1 scores, TOEFL scores, copies of diplomas and letters of evaluation) can be carried forward if they are available from our record archives. In addition to all application documents mentioned, reapplicants must also submit a reapplication statement describing any changes from previous applications relating to NBDE scores, TOEFL scores, educational experience, and/or work experience, if applicable. Serious consideration will be given to those with exceptional academic records and credentials. Failure to submit a reapplication statement will reduce interview consideration. Please note that TOEFL Scores must be current within two years of September 1, 2011.

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ESSAY QUESTIONS AND ADDITIONAL INFORMATION Please type your responses to each of the following questions in question/answer format, and attach them to this application. Although there is no maximum length to responses, please convey your thoughts adequately and in a reasonable amount of space. 1 2 3 4 5 6 Please list any extracurricular activities or leadership positions held in dental or professional school and include dates and total hours of your participation and a description of activities. Please list any volunteer of community service activities and include dates and total hours of participation, name of organization and location of activities. What activities have you performed that demonstrate your ability to work effectively with people? Please describe your immediate and long-term professional goals. Describe (if applicable) your work experience (paid or unpaid) in the U.S. or Canada and how it contributes to your professional experience. What qualities of the University of Pennsylvania School of Dental Medicine do you feel will help you achieve your professional goals and how?

CERTIFICATION Please read and sign the certification below: I hereby certify that I provided accurate information in this application. I understand and agree that any misrepresentation or omission of facts in my application will justify the denial of admission, the cancellation of admission or expulsion. I also understand that all matriculated students are required to undergo a Criminal Record Check and Child Abuse History Clearance in order to treat minor patients in the Commonwealth of Pennsylvania. I also understand that I will be responsible for payment of such fees (approximately $60$100 per year). Signature ___________________________________________________________________________ Date ______________________________________ APPLICATION CHECKLIST You must submit the following documents to be considered for an interview. Notarized photo copies of the official document must bear the original notary stamp. For serious consideration, all items should be received at Penn Dental Medicine Office of Admissions a month in advance of the September 1, 2011 deadline. All application materials and documents become the property of the University of Pennsylvania School of Dental Medicine and will not be returned to the applicant. 1 2 3 Program for Advanced Standing Students Supplemental Application must be submitted to Penn Dental Admissions Office. Essay responses to items 16, in question/answer format must be submitted to Penn Dental Admissions Office. Application fee of $75. Checks or money orders in U.S. dollars should be made payable to the Trustees of the University of Pennsylvania must be submitted to Penn Dental Admissions Office. 4 Official National Dental Board Examination (NBDE) Part 1 scores must be submitted to Penn Dental Admissions Office. 5 Official TOEFL (Test of English as a Foreign Language) scores must be submitted to Penn Dental Admissions Office. 6 Notarized copy of dental school transcript must be submitted to Penn Dental Admissions Office. 7 Notarized copy of official dental school diploma or certificate of graduation must be submitted to Penn Dental Admissions Office. 8 Official transcripts from U.S. colleges or universities for any coursework completed in the U.S. 9 Official copy of the ECE Course-by-Course Evaluation Report and G.P.A. must be submitted to the CAAPID Application Service. 10 Three letters of evaluation should be submitted to the CAAPID Application Service. PLEASE SUBMIT CHECKLIST APPLICATION ITEMS 18 ABOVE TO: Office of Admissions-PASS Program Robert Schattner Center University of Pennsylvania School of Dental Medicine 240 South 40th Street, Room 122 Philadelphia, PA 19104-6030

If you have any questions regarding the admissions process, contact (215) 898-0558 from 9:00 AM to 4:30 PM or sdm-pass@pobox.upenn.edu
The University of Pennsylvania values diversity and seeks talented students, faculty and staff from diverse backgrounds. The University of Pennsylvania does not discriminate on the basis of race, color, sex, sexual orientation, gender identity, religion, creed, national or ethnic origin, citizenship status, age, disability, veteran status or any other legally protected class status in the administration of its admissions, financial aid, educational or athletic programs, or other University-administered programs or in its employment practices. Questions or complaints regarding this policy should be directed to the Executive Director of the Office of Affirmative Action and Equal Opportunity Programs, Sansom Place East, 3600 Chestnut Street, Suite 228, Philadelphia, PA 19104-6106; or (215) 898-6993 (Voice) or (215) 898-7803 (TDD). Specific questions concerning the accommodation of students with disabilities should be directed to the Office of Student Disabilities Services located at the Learning Resources Center, 3820 Locust Walk, Harnwell College House, Suite 110, (215) 573-9235 (voice) or (215) 746-6320 (TDD). Federal law, the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, requires all institutions of higher education to provide information on their security policies and procedures and specific statistics for criminal incidents and arrests on campus to students and employees, and to make the information and statistics available to prospective students and employees upon request. The Pennsylvania Uniform Crime Reporting Act requires Penn to provide information about its security policies and procedures to students, employees and applicants; to provide crime statistics to students and employees, and to make those statistics available to applicants and prospective employees upon request. The information about Penn is available at http://www.publicsafety.upenn.edu/resources/cleryreport.asp or by calling the Division of Public Safety at (215) 898-4481.