PAPER APPLICATION CHECK LIST
**THIS APPLICATION/CHECKLIST ONLY APPLIES TO THOSE WHO ARE BYPASSING CAAPID AND IS SUBMITING
APPLICATION DIRECTLY TO SCHOOL OF DENTAL MEDICINE.
APPLICATION DEADLINE IS March 01, 2015 (No exceptions will be made).
Before sending in your application, please make sure all documents listed below are included. Failure to provide with required
documents before the deadline will result in application not being reviewed without refund of the application fee.
PLEASE SUBMIT THE FOLLOWING DOCUMENTS IN THE ORDER LISTED BELOW (Please note, our program DOES NOT require sealed
envelopes for documents:
COMPLETED APPLICATION FORM (Signed and Dated)
Please clearly print or type.
PERSONAL STATEMENT
DENTAL EXPERIENCE
This may be in the form of an essay, resume, or curriculum vitae.
OFFICIAL COURSE-BY-COURSE EVALUATIONS
Official ECE (www.ece.org) course-by-course evaluation. No actual college transcripts will be accepted unless you have done any studies in the United
States. Please make sure the document submitted is labeled ‘Course-By-Course Evaluation’.
TRANSCRIPTS
You must include any Transcripts from any US institution or post-doctoral programs that you may have with your supplemental documents
DENTAL DEGREE
School certified or notarized copy; if in a language other than English, a translation must be made by a U.S. translator and notarized by a bonafide
notary public. Please note that no provisional degrees are accepted.
NATIONAL BOARD DENTAL EXAMINATION- PART I
Original National Board Dental Examination Part I score report. There is no cut off score for NBDE Part I; only a passing score is required. Part II is
encouraged, however, is not required. If Part II has been taken, scores need to be submitted before the deadline to be considered as part of the
application.
TEST OF ENGLISH AS A FOREIGN LANGUAGE (TOEFL)
Original results of having successfully received a minimum score of 94 on the internet-based version of the exam. Score received at the time of
application being submitted must be less than 2 years old from the date exam was taken. All applicants must take TOEFL, regardless of residency
status or circumstances. You will need to submit TOEFL even if you are a US citizen/resident, grew up in the US, hold any other type of U.S. degrees
(BS, MS, MBA, PhD), or even if currently enrolled in a different institution. No other English skill exams may replace TOEFL.
THREE LETTERS OF RECOMMENDATIONS
The recommendation letter will not be accepted if the letter is older than 12 months from the date it was written at the time of application being
submitted. Letters should be in English, or translated by a bonafide U.S. translator if it was written in language other than English. Sending in more than
the required number of letters will not be given any priority over other applicants. Letters must include contact information of author, phone number,
email address, physical address/school or office physical address. Please use form attached to indicate whether or not you waive the right to see each
letter or do not waive the right.
Letters may come from dentists, non-dentists, deans, educators of various post graduate programs the applicant may be enrolled or have enrolled in, from
current or past employers and charities volunteered for. The letters of evaluation should come from those who have direct and current knowledge of the
applicant and should address the applicant’s work ethic, personality, knowledge base, personal skills, clinical dental skills character and reliability
BOARD OF REGENTS QUESTIONNAIRE
APPLICATION FEE
A non-refundable application fee of $400.00 in the form of a cashier’s check or money order; please make checks payable to University of Colorado
School of Dental Medicine (UCSODM).
All application, required documents and fee must be received by March 1, 2015. Any documents received after this date will not be
considered as part of the application. Once your application is received, an email confirmation stating the status of the application will be
sent out. Please note that admission process is not on a rolling-basis, therefore, applicants will receive notice of decision after the proposed
deadline.
Note: For translations you may contact:
1. Contact your school for certified/notarized translation; or
2. A translator accredited by the American Translators Association (www.atanet.org) or 703.683.6100
3. Certified or registered court interpreter. Information on court interpreters is available through the Judicial Council at 415.865.7530. General
information is provided at www.courtinfo.ca.gov. The court interpreter must sign the translation and declaration in the presence of a Notary
Public.
MAILING ADDRESSES TO SUBMIT APPLICATION:
UNIVERSITY OF COLORADO
SCHOOL OF DENTAL MEDICINE
INTERNATIONAL STUDENT PROGRAM
ATTN: BEATRIZ BUSTAMANTE
MAIL STOP F838
13065 E. 17th Ave Suite 403
AURORA, CO 80045
UNIVERSITY OF COLORADO
SCHOOL OF DENTAL MEDICINE
INTERNATIONAL STUDENT PROGRAM
PROGRAM APPLICATION Class of 2017
Last Name/Family Name, First Name, Middle Name
Other Name (Please list any other name that will appear on your academic records): ________________________________________________________
Personal Data
Gender:
US Visa type (if applicable)
Date of Birth: (MM/DD/YYYY)
# Of years living in US:
Country of Birth:
US Social Security number (if applicable):
Country of Education:
Country of Citizenship:
Current Mailing Address:
Street:
City:
State/Province:
Zip Code:
State/Province:
Zip Code:
Country:
Primary Phone: (
Secondary phone: (
)
)
E-mail (required) (print clearly)
Permanent Mailing Address (if different than above)
Street:
City:
Country:
TOEFL Score
Total Score:
Date:
Test type:
National Board Dental Examination Scores (including new and old NBDE Formats)
Total Score:
Part I Date (s):
Total Score:
Part II Date (s) (if taken):
EDUCATION HISTORY
List all schools attended, starting with most recent education/program
Full Name of Institution
Location of Institution
(City, Country)
Start Date-End Date
Course of Study
Degree Earned
Month & Year
Date of
Degree
If you attended additional schools, write them on an attached sheet.
Practice of Dentistry Experience:
Name of Employer:
Dates:
Address:
Hour/Week:
Volunteer:
Received salary/payment/academic credit:
Name of Employer:
Dates:
Address:
Hour/Week:
Volunteer:
Received salary/payment/academic credit:
Name of Employer:
Dates:
Address:
Hour/Week:
Volunteer:
Name of Employer:
Received salary/payment/academic credit:
Dates:
Address:
Hour/Week:
Volunteer:
Received salary/payment/academic credit:
Other work experience: (include dental assisting here)
Name of Employer:
Dates:
Address:
Hour/Week:
Received salary or payment:
Volunteer:
Teaching Experience (Please use additional paper to describe)
Name of Employer
Dates:
Currently Employed:
Hour/Week:
Address:
Received Academic Credit:
Received salary or payment:
Experience:
Research Experience (Please use additional paper to describe)
Volunteer:
Externships, Publications, Conference Presentations (Please use additional paper to describe)
Other Relevant Information
Background Questions
Have you ever been licensed in any country as a dentist?
Yes
No
Yes
No
Yes
No
Yes
No
If Yes, which country/(countries):
Have you ever been dismissed from any college, university, or professional school?
If Yes, please attach a statement of explanation.
Were you ever subject to any disciplinary action by any college, university, or professional school?
If Yes, please attach a statement of explanation.
Have you ever been subjected to disciplinary action by any professional licensing board?
If Yes, please attach a statement of explanation.
What is your native language?
What language was used in your study of dentistry?
Other language (s)?
Speak
Read
Write
Speak
Read
Write
Speak
Read
Write
How did you hear about this program?
Do you have relatives/friends who are associated with this program?
Yes
No
If yes, please list their names and your relationship with them.
Do you have any relatives who are dentists, are in Dental School, or who have studied or are studying dental hygiene or dental assisting,
Dental laboratory Technology or related dental fields?
Yes
No
If yes, please indicate name, relationship, name of school, dental degree or certificate, year of graduation or expected
graduation:_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Have you ever applied to this dental school prior to the present application cycle?
Yes
No
Yes
No
If yes, list all year (s) applied.
Have you ever attended University of Colorado SODM ISP personal interview and bench exam?
If yes, list all year (s)
“I certify that the information given in this application is accurate and complete to the best of my knowledge. I understand that I am responsible for forwarding any
required pre-dental and dental documentation/records to the International Student Program. I also understand that failure to provide complete or truthful
information will lead to a denied application or enrollment status. I further understand that my deposit will be non-refundable upon dismissal of application or
enrollment based on false or missing information”.
Date _____________
Applicant's Signature: ______________________________________________________
UNIVERSITY OF COLORADO
SCHOOL OF DENTAL MEDICINE
INTERNATIONAL STUDENT PROGRAM
Letter of Recommendation Form
Applicant Name:
Name of Person Providing a Recommendation (Please provide one form per recommendation letter):
The Family Educational Rights and Privacy Act (FERPA) provides that each applicant will have the right of access to
his/her letters of recommendation. Check one box and sign below the appropriate statement.
___________
___________
I hereby waive my right of access to this information and authorize the above named person to
provide a candid evaluation and all relevant information to the University of Colorado
School of Dental Medicine. By waiving this right of access, I understand that the University of
Colorado School of Dental Medicine will hold this completed form in confidence from me to the
extent permitted by law.
I do not waive my right to access to this recommendation, but authorize the above-named
person to provide a candid evaluation including all relevant information to the university of
Colorado
Applicant's Signature:
________________________________________________________________
Date:_______________________
UNIVERSITY OF COLORADO
ANSCHUTZ MEDICAL CAMPUS
SCHOOL OF DENTAL MEDICINE
BOARD OF REGENTS QUESTIONNAIRE
The University of Colorado requires that all applicants provide information concerning any past felony or
misdemeanor records. This is a rule, not of the Dental School, but of the University of Colorado Anschutz
Medical Campus system imposed by the Board of Regents.
While the record of a conviction would not necessarily prevent an applicant from being accepted or enrolled at
the School of Dental Medicine, failure to provide information concerning such conviction would prevent
matriculation of dismissal if the information were later revealed, thus indicating that the applicant had falsified
the report.
In compliance with this regulation, as required by the Board of Regents of the University of Colorado, you must
answer, sign, and submit as part of your formal records, the following questions.
Please respond to the following questions in the most complete and accurate manner possible. Do
not identify convictions for which the criminal record has been expunged or sealed by the court.
For purposes of the following questions, a “conviction” means guilty verdict, guilty plea or a No
Contest plea.
Have you ever been convicted of a felony? Yes_____ No _____
If yes, please give details including date, state/county court in which conviction was entered, type of felony, etc. by
attaching a statement of explanation.
_____________________________________________________________________
Have you ever been convicted of a misdemeanor? Yes_____ No _____
If yes, please give details including date, state/county court in which conviction was entered, type of misdemeanor, etc. by
attaching a statement of explanation.
_____________________________________________________________________
I hereby certify that to the best of my knowledge the information above is true and complete. I understand that
if found to be otherwise, it is sufficient cause for rejection or dismissal.
Applicant Signature_______________________________________________ Date __________________
Print Name_____________________________________________________
Rev. 9/10