U Penn Application

PROGRAM FOR ADVANCED STANDING STUDENTS
2018–2019 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 __________ City and Country of Birth _____________________________________________
Please list your current place of residence if different from mailing address listed on CAAPID application.
Street Address _____________________________________________________________________________________________________________
City ____________________________________________ State ___________________________ Zip or Postal Code _________________________
Country __________________________________________________________________________________________________________________
Have you applied to the University of Pennsylvania School of Dental Medicine’s PASS program before? Yes No
If yes, please indicate the most recent application year _______________________________________________________________________________
REAPPLICANTS
All reapplicants must submit a CAAPID application, Penn Dental PASS Supplemental Application, essay responses, and application fee. Documents
from prior application (NBDE Part 1 scores, TOEFL scores and letters of evaluation) can be carried forward if they are available from our record
archives. Reapplicants must complete questions 1–3 under the Custom Questions section on CAAPID regarding PREVIOUS APPLICATIONS TO US
DENTAL SCHOOL. Serious consideration will be given to those with exceptional academic records and credentials. Please note that TOEFL Scores
from 2015 and earlier will not be considered.
CLINICAL TRAINING/EXPERIENCE
Please indicate your clinical experience in each of the follow dental disciplines by selecting the appropriate response. You may add any comments
to describe your clinical training or experience in these areas on a separate sheet of paper. Please specify only hands on experience (not
observership).
Comprehensive (general) dentistry Extensive Moderate Minimal

Prosthodontics:
Removable Extensive Moderate Minimal
Fixed Extensive Moderate Minimal
Implants:
Placement Extensive Moderate Minimal
Restoration Extensive Moderate Minimal
Periodontics Extensive Moderate Minimal
Pediatric dentistry Extensive Moderate Minimal
Endodontics:
Simple Extensive Moderate Minimal
Molar Extensive Moderate Minimal
Orthodontics Extensive Moderate Minimal
Oral Surgery Extensive Moderate Minimal
Oral Medicine Extensive Moderate Minimal
Diagnosis/treatment planning Extensive Moderate Minimal
Special needs patients Extensive Moderate Minimal
Adhesive restorative materials Extensive Moderate Minimal
CAD-CAM/digital restorative Extensive Moderate Minimal
Continued on page 2
For office use only: Fee PD ______________
PROGRAM FOR ADVANCED STANDING STUDENTS
2018–2019 SUPPLEMENTAL APPLICATION
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 What activities have you performed that demonstrate your ability to work effectively with people?
2 Please describe your immediate and long-term professional goals.
3 Describe (if applicable) your work experience (paid or unpaid) in the U.S. or Canada and how it contributes to your professional experience.
4 What qualities of Penn 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–$125).
Signature __________________________________________________________________________ Date ______________________________________
APPLICATION CHECKLIST
You must submit the following documents to be considered for an interview. For serious consideration, all items should be received a month in
advance of the June 1, 2018 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 Program for Advanced Standing Students Supplemental Application must be submitted to Penn Dental Admissions Office.
2 Essay responses to items 1–4, in question/answer format must be submitted to Penn Dental Admissions Office.
3 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. Electronic or cash payments are not accepted.
4 Official National Dental Board Examination (NBDE) Part 1 scores must be submitted electronically to CAAPID Application Service.
5 Official TOEFL scores should be submitted electronically to CAAPID Application Service.
6 Official copy of the ECE Course-by-Course Evaluation Report and G.P.A. must be submitted to the CAAPID Application Service.
7 Three letters of evaluation on official letterhead with signature should be submitted to the CAAPID Application Service.
PLEASE SUBMIT CHECKLIST APPLICATION ITEMS 1–3 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 [email protected]
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).
The federal Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, as amended, requires colleges and universities to provide information related to
security policies and procedures and specific statistics for criminal incidents, arrests, and disciplinary referrals to students and employees, and to make the information and statistics
available to prospective students and employees upon request. Federal law requires institutions with on-campus housing to share with the campus community an annual fire
report. In addition, the Uniform Crime Reporting Act requires Pennsylvania colleges and universities to provide information related to security policies and procedures to students,
employees and applicants; to provide certain crime statistics to students and employees, and to make those statistics available to applicants and prospective employees upon
request. You may view the report at www.publicsafety.upenn.edu/clery/ or request a paper copy of the report by calling the Division of Public Safety’s Special Services
Department at 215-898-4481.

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PROGRAM FOR ADVANCED STANDING STUDENTS

2018–2019 SUPPLEMENTAL APPLICATION

Last Name _____________ First Middle

Maiden Name (if applicable) __________________________________________________________ Male Female

CAAPID ID # DENT PIN #

Street Address _____________________________________________________________________________________________________________

City ______________________________ State _ Zip or Postal Code _____________

If yes, please indicate the most recent application year _______________________________________________________________________________

Comprehensive (general) dentistry Extensive Moderate Minimal

ESSAY QUESTIONS AND ADDITIONAL INFORMATION

Signature ____________________________________ Date

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