Personal Information
 
 First Name:  M.I.   Last Name: 
 Date of Birth:   Sex: Female   Male 
 Country of Citizenship:   Present Address
  
 Street/Address: 
     Apt./Box #: 
           City: 
 State/Province: 
        Country: 
    Postal code: 
 
      Telephone: 
  Email address:   Permanent Address (if different than above)
 
 Street/Address: 
     Apt./Box #: 
           City: 
 State/Province: 
        Country: 
    Postal code: 
 
      Telephone: 
  Email address:  

Education Record

 University: 
 Degree:  GPA/Class Rank:   Major: 
            Matriculation Date: 
 (Expected) Date of Graduation:   If you have attended more than one institution, please
 list the most recent above and include the next most recent below:
  
 University: 
 Degree:  GPA/Class Rank:   Major: 
            Matriculation Date: 
 (Expected) Date of Graduation: 
 
 Please have official transcripts sent from your undergraduate
 institution and your dental school.  Indicate here the date you
 requested the transcripts to be sent:  
 
 List at least 2 faculty members who have been asked to write
 letters of recommendation on your behalf:
 
 Name:  Title: 
       Telephone:  
 Name:  Title: 
       Telephone:  
 Name:  Title: 
       Telephone:  
 
 Trainees will receive a stipend of approximately $3,400
 for the two-month period of training.  In addition, housing will be 
 provided by the University of Rochester. 
 Some dental schools provide travel assistance for students
 in this program.  If such aid is unavailable or insufficient,
 some assistance for travel costs may be available for applicants
 who can demonstrate clear financial need.  To apply for
 travel assistance, please have the financial aid officer
 of your dental school send a letter in support of your request,
 documenting your need.
 
 Indicate whether or not you will request
 financial assistance:  Yes   No 
 
 The Program will run from approximately May 30 through August 10. 
 Please indicate any time during this period that you
 would be unable to participate (for example, due to
 National Boards, family obligations, etc.):   

 Personal Statement
  
 Please answer the following questions.
 Since we are unable to interview candidates,
 your answers play a large role in our decisions.
 
 Why do you wish to participate in this program?
 
 
 If you have participated in research-related acitivites,
 please describe them:
 
 
 What are your scientific research interests?
 
 
 What are your career goals?
 
 
 How will this experience assist you in reaching
 your long-term career goals?
 
 
 What do you consider to be your greatest
 personal strength?  Weakness?  Why?
  

 For U.S. citizens and permanent residents only.
 

 How would you describe yourself?  (Please check one).
 African American                                          
 American Indian or Alaskan Native                         
 Asian or Pacific Islander (including Indian subcontinent) 
 Hispanic (including Mexican American; not Puerto Rican)    
 Puerto Rican                                               
 White, Anglo, Caucasian American (non-Hispanic)           
 Other                                                      

 

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