2012 UCSF DENTAL POST-BACCALAUREATE APPLICATION INSTRUCTION SHEET
Please read the following instructions carefully so that you may correctly complete and submit an application to
the UCSF Dental Post-baccalaureate program.
I.
General Instructions
1. This program is only open to US Citizens and Permanent Residents. Preference is given to California residents.
2. You must complete and return all forms included in this application, and all requested documents must be
received by the application deadline in order to be considered for the program.
3. You should complete these forms on your computer and then print them for signing and mailing. Do NOT
complete by hand. Handwritten applications will be subject to cancellation.
4. You must use the forms provided, and your replies must fit in the space provided. Each short-answer response is
limited to 2000 characters including spaces.
5. Do not attempt to adjust the font or type size in the forms. Any attempt to change the font or type size could result
in your application being canceled for failing to adhere to the guidelines provided.
6. Do not include any additional materials or pages unless the instructions indicate this is allowed. Any such
materials received will be discarded and will not be included in your application folder.
*Failure to follow all instructions, and fill in all forms completely and correctly could result in your application
being canceled.
II. Completing the Application
1. Part I: Personal Information. Please provide all required information.
2. Part II: Academic Background.
a. In the first table, please list the course work you completed to fulfill the dental school prerequisites.
b. In the second table, list any course work that may not yet appear on transcripts (in progress and/or planned).
3. Part III: Supplementary Questions. You may only use the space provided to answer these questions. Please
avoid repeating information already outlined in your AADSAS personal statement.
4. Part IV: Recommendation. You must submit one recommendation from a college professor supporting your
application to the post-baccalaureate program.
a. Complete and sign section A before giving the form to your letter writer.
b. This letter must be sent directly from the letter writer to UCSF in a sealed school envelope bearing the
signature of the letter writer across the back flap.
5. Additional Materials.
a. If you previously applied to dental school, you must submit a copy of your most recent AADSAS application.
b. If you have previously taken the DAT, you must submit an unofficial copy of your score report.
c. You must submit unofficial copies of transcripts for all college level work you have completed through the fall
2011 term.
III. Submitting the Application. After you have completed the entire application, mail it along with any applicable
materials indicated in instruction point # 4, to:
UCSF School of Dentistry
Post-Baccalaureate Program Admissions
Box 0430
San Francisco, CA 94143-0430
UCSF SCHOOL OF DENTISTRY POST-BACCALAUREATE APPLICATION
Part I: Personal Information
Last Name
First Name
MI
Dent PIN (If existing)
Street Address
AADSAS ID (If existing)
City
Phone
Alternate Phone
Date of Birth:
Gender:
Are you a California Resident?
If No, give State of Residence:
State
Zip
Email Address
Are you a U.S. Citizen?
If No, give Visa status:
Place of Birth:
Primary language spoken at home:
Other language(s) / Fluency (High, Medium, Low):
FAMILY BACKGROUND
Father/Guardian
Mother/Guardian
Occupation
Highest level of education completed
RACE & ETHNICITY (OPTIONAL)
1. Do you consider yourself to be of Spanish/Hispanic/Latino/Latina ethnicity?
Cuban
Mexican, Chicano/Chicana
Puerto Rican
If yes, check all that apply:
South or Central American
Other:
2. What is your race (check all that apply)?
American Indian or Alaska Native Enrolled or principal tribe:
Asian (Please specify):
Black or African American
Native Hawaiian or other Pacific Islander (Please specify):
White
Do you come from a disadvantaged background (see below)?
No
Yes
An individual is considered to be “disadvantaged” if either of the 2 conditions apply:
1. S/he comes from an environment that has inhibited the individual from obtaining knowledge, skill, and ability to enroll in and graduate
from a health professions school.
2. S/he comes from a family with an annual income below a level based on low-income thresholds according to family size as described in
this table:
HHS Poverty Guidelines
# Persons in Family
Continental US & DC
Alaska
Hawaii
1
$10,830
$13,530
$12,460
2
14,570
18,210
16,760
3
18,310
22,890
21.060
4
22,050
27,570
25,360
5
25,790
32,250
29,660
6
29,530
36,930
33,960
7
33,270
41,610
38,260
8
37,010
46,290
42,560
For each additional person, add:
3,740
4,680
4,300
UCSF School of Dentistry Post-Baccalaureate
Application
Last Name
Part II: Academic Background
First Name
MI
DentPIN
AADSAS ID
You must have earned a Bachelor’s degree to be eligible for this program. Have you earned a Bachelor’s degree?
No
Name of College or University:
Degree (B.S., B.A., Other):
Major:
Date Conferred:
Cumulative GPA:
Have you previously applied to dental school? If yes, please list schools and application cycles below. Attach
additional pages as needed. You must also attach a copy of your most recent AADSAS Application.
Example: 2010-UCSF, UOP, USC; 2009-UOP, USC, Loma Linda
No
Have you previously taken the DAT (If yes, list dates and scores below. Attach additional pages as needed)?
Date
Academic Average
PAT
Quant. Reas.
Reading Comp.
Biology
No
Chem. Inorg.
Chem. Org.
Yes
Yes
Yes
Total Science
1.
2.
3.
DENTAL PREREQUISITE STATUS: You must account for all prerequisites in the table below. 1 semester unit = 1.5 quarter units.
Abbreviate as necessary. Attach additional sheets if needed.
Dental Prerequisites
Course #
Grade
Qtr Units
School
Term
Year
Sample Course
General Chemistry w/ Lab
Biol 150
A-
4.5
UC Berkeley
Wi
2007
In Progress/Planned
(2 semesters or 3 quarters)
Organic Chemistry w/ Lab
(2 semesters or 3 quarters)
General Biology/Zoology w/ Lab
(2 semesters or 3 quarters) Note:
Anatomy and Physiology will not fulfill this
requirement
General Physics w/ Lab
(2 semesters or 3 quarters)
Biochemistry (4 qtr units)
Psychology (1 semester or quarter)
English Literature and Composition
(2 semesters or 3 quarters)
Use the table below to list any in progress or planned course work for the winter, spring, summer and/or fall 2012 term(s).
Course Name
Course # Qtr Units
School
Term / Year
In Progress/Planned
Introd. Biology
Bio 1A
UC Tahoe
Spring / 2011
Planned
6.0
UCSF School of Dentistry Post-Baccalaureate Application
Last Name
First Name
Part III: Supplementary Questions
MI
DentPIN
AADSAS ID
Please answer the following questions using only the space provided. Do not use any special formatting such as
bold, italics, or underlining.
1.
Explain why you believe you are not currently a competitive applicant to dental school? If you have previously
applied and been denied admission to dental school, please explain why you believe you were denied. If you have not
previously applied to dental school please explain why you want to complete a post-baccalaureate program before
applying.
2. Describe any barriers you may have had to overcome in achieving your educational objectives and how you
overcame these barriers. These could include any or all of the following: educational and economic barriers, or other
hardships that you have overcome.
3. Explain why any barriers you discussed in question 2 will no longer be a hindrance to your success in the postbaccalaureate program and dental school.
UCSF School of Dentistry Post-Baccalaureate
Application
Part II: Academic Background
Last Name
First Name
MI
DentPIN
AADSAS ID
4. Discuss your contributions to your community. Focus on any special skills or insight you have gained or developed,
and how this will influence your future practice as a dentist.
5. Explain what you feel the post-baccalaureate program has to offer you, and why you believe you would be a good fit
for the program.
Statement of Authenticity: I certify that the information submitted on this form is true and correct. I agree to provide, if requested, any official documentation necessary to verify this
information. I understand that false statements or misrepresentation in any part of this application may result in an admission offer (if offered) to the University of California, San Francisco
Dental Post-Baccalaureate Program being revoked. I also consent to any investigation for clarification or verification of the information provided.
Signature
Date
UCSF School of Dentistry Post-Baccalaureate Application
Last Name
First Name
Part IV: Recommendation
MI
DentPIN
AADSAS ID
Section A: Waiver of Access. Please make a selection:
By “waiving your right to access,” you give up the right to read the evaluation once completed by the evaluator.
By “not waiving your right of access,” you have the right to read the evaluation once completed by the evaluator.
I waive my “right of access” to the attached recommendation.
I do not waive my “right of access” to the attached recommendation.
Applicant Signature
Date
Evaluator Information. Dear letter writer, thank you for agreeing to provide a recommendation for the above
listed applicant to the UCSF Dental Post-baccalaureate program. This program is an intensive 11 month
academic enhancement program designed to make participants more competitive in the dental school
admissions process. Please provide the information requested below, attach this form to your letter and return
to us in an official institution envelope with your signature across the back flap. Thank you!
Name:
Institution:
Street Address:
City, State, ZIP
Email Address:
Phone Number:
Return this form and your letter of recommendation to:
UCSF School of Dentistry
Post-Baccalaureate Program Admissions
Box 0430
San Francisco, CA 94143-0430