New York University College of Dentistry

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Online Application

Supplemental Application For Admissions

Applying for Fall 200

Name in Full

First Name:

Middle Name:

Last Name:

Present Address

No:

Street:

Apt.:

City:

county:

State:

Zip:

Telephone:

Permanent Address

No.:

Street:

Apt.:

City:

county:

State:

Zip:

Telephone:

Email Address:

After what date should we use permanent Address?:

Fax:

Alternate Telephone:

1.	Complete this application and submit online or print a hard copy and mail to Juliana Cools, Clinical Research Program, Department of Epidemiology and Health Promotion, New York University College of Dentistry, 345 East 24th Street, New York, New York 10010-4086.

2.	A check or money order in the amount of $100 made payable to New York University College of Dentistry must accompany the application. The application fee is non-refundable and will not be applied toward tuition.

3.	Three letters of reference should, preferably, be submitted with this application or as early as possible.

4.	The deadline for receipt of applications is February 28, of the year in which admissions is sought. (Depending on the availability of slots, late applications received up to June 30th will be considered).

5.	Upon admission, if not included in the original application, the applicant must arrange for an official transcript from his/her undergraduate college to be sent to the Office of Student Affairs and Admissions.

Academic Background

List all high schools, colleges, universities, graduate and professional schools attended.

	Name of Institution	Location	Attended From To	Major Field	Degree	Date of Graduation
Secondary School:

Colleges:




Graduate and Professional Schools:

List the significant student activities in which you participated and offices held during college.

List all scholastic honors you received during college.

List all community activities in which you have participated.

Additional Information

GRE results:
Year:	Score:

TOEFL results, if applicable:
Year:	Score:

National Board results, if applicable:
Year:	Score:

The Dental Admissions Test, if applicable. List the most recent date on which you have taken or plan to take the DAT.

DAT Scores

Most Recent Date:				Future Test:
Academic Avg.	PAT Avg.	Quant Reas.	Read Comp.	Biology	Chem Inorg.	Chem Org.	Total Sci.

Have you ever been expelled, suspended, disciplined or placed on academic probation at any institution?

Yes No

Have you ever been convicted of a felony, misdemeanor or other crime?

Yes No

If yes to either question, please state details including name of institution and reason.

List the names of any members of your family who have attended New York University College of Dentistry, their class and relationship to you.

Do you plan to apply to Financial Aid

Yes No

Do you plan to apply to University Housing?

Yes No

Certification
I certify that the answers to the above questions are complete and accurate and I understand and agree that any omission or misstatement in the answering of any questions in this application, whenever discovered, may result in the voiding of my registration in which event I will receive no credit for attendance at the College. It is my understanding that my connection with the College may be terminated at any time whenever, in the opinion of the Dean, my individual conduct, scholastic standing or other circumstances may require it. I have read the College's recent catalogue and agree to abide to all the rules, regulations and directions of the College so far as they affect me and understand that the rules, regulations and directions of the College are subject to change without notice.

I Agree

Statistical Information (optional)

Sex: Male Female

Ethnic Background:

White - not of Latino origin

Black - not of Latino origin

Latino

Asian or Pacific Islander

American Indian or Alaskan Native American

Current Status:

U.S. Citizen

Permenant Resident

Student Visa

Other type of Visa(specify)

Alien (Registration Number)

Refugee

Date of Birth:

Place of Birth:

Citizenship: