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VIEWS: 10 PAGES: 4

									                    UNIVERSITY
OF
ALABAMA
AT
BIRMINGHAM

                            SCHOOL
OF
DENTISTRY

                         DENTAL
ASSISTING
PROGRAM

                                      

                                      

                                 APPLICATION
FOR
ADMISSION

                                              

                                                                                   

    Please
type
or
print
neatly
using
dark
ink

                                                  

   INSTRUCTIONS
FOR
APPLICATION
TO
PROGRAM:

   

   1.
   When
making
application,
please
mail
completed
application
and
forward

         official
transcripts
from
high
school
and
colleges
to:

   

                                  Dental
Assisting
Program

                                   UAB
School
of
Dentistry

                                          SDB
Box
39

                                   1919
7th
Avenue
South

                                Birmingham

AL
35294‐0007

   

   2.
   You
must
take
the
ASSET
placement
test
administered
by
the


   
     UAB
1‐Step
Office.

Call
to
schedule
at:

   

                                 HILL
UNIVERSITY
CENTER

                                    1400
University
Blvd.

                                     4th
Floor,
Room
470

                                        205‐934‐5503

                                                

   3.
   Enclose
current
photograph
with
application.

   

   4.
   Schedule
information
session
with
Dental
Assisting
Program

   
     faculty
member.

Call:

   

                                    Ms.
Dorothy
Andrews

                                        205‐934‐5234

                                                

                                                

                                                

                                        IMPORTANT:

                                                

         YOUR
APPLICATION
IS
NOT
CONSIDERED
COMPLETE
UNTIL
YOUR

APPLICATION
FORM
IS
SUBMITTED,
ALL
TRANSCRIPTS
AND
ASSET
SCORES
HAVE

        BEEN
RECEIVED
AND
THE
INFORMATION
SESSION
ATTENDED

                                                

                                                

                                                

                                                

                                                

    
                                             1

                                                 

                                                 



APPLICATION
INFORMATION






   
    
    
   
   
                          
       
       
       
       
        
     

NAME

     (First)

     
        (Middle)
            
        
     (Last)




    
     
       
     
        
         
          
        
     
          
       
      

ADDRESS
 (Number)
       
        (Street)




    
     
       
     
        
         
          
        
     
          
       
      


    
     (City)
 
     
        (State)

            
        
     (Zip)




    
     
       
     
        
         
          
        
     
          
       
      

PHONE
     (Home)
       
        (Cell)
 
            
        
     (Work)




    
     
       
     
        
         









ETHNICITY

 
              
       
      

E­MAIL
ADDRESS




    
     
       
     
        
         









SEX:




 Female

(


)



Male

(


)

BIRTHDATE
 (Month,
Day,
Year)



ALABAMA
RESIDENT



Yes

(


)


No


(


)










US

CITIZEN



 Yes

(


)

No

(


)



SOCIAL
SECURITY
#
 
     
        
         
          
        
     
          
       






    
     
       
     
        
         
          
        
     
          
       
      

NAME
TO
CONTACT
IN
CASE
OF
EMERGENCY
 
                         
     PHONE







EDUCATION




   
   
               
       
       
        
       
       
       
       
        
     

HIGH
SCHOOL
           (NAME)
     
  (CITY)

      
      (STATE)





CHECK
STATUS
THAT
APPLIES
TO
YOU:



(


)
 Regular
high
school
diploma
   
      Graduation
date
    
                        
     

(


)
 Certificate
of
completion
 
   
      Graduation
date
    
                        
     

(


)
 Completion
of
GED
 
        
  
      Date
received





 
                        
     

(


)
 Not
a
high
school
graduate








                                    2



Are
you
currently
or
have
you
ever
been
enrolled
at
UAB?




Yes
(



)



No

(



)





LIST
ALL
SCHOOLS
OR
COLLEGES
ATTENDED
SINCE
LEAVING
HIGH

SCHOOL,
INCLUDING
ANY
CURRENT
OR
ANTICIPATED
ENROLLMENT.



   Name
of
Institution
      City
&
      Dates
      Graduate
            Degree

                             State
      Attended
      Y/N
               Earned

                                                                                     

              
                     
              
              
                  

    
                        
              
                 
              

    
                        
              
                 
              

    
                        
              
                 
              







HONORS,
AWARDS
OR
SCHOLARSHIPS
RECEIVED




   
     
    
     
    
     
    
                    
       
      
       
       




   
     
    
     
    
     
    
                    
       
      
       
       







WORK
EXPERIENCE





START
WITH
YOUR
PRESENT
POSITION
AND
WORK
BACK



  Name
of
Employer
       Title/
     Dates:
       Duties


                          Position
   To
­
From
 Performed

  
                       
           
             

  
                       
           
             

  
                       
           
             

  
                       
           
             





SPECIAL
QUALIFICATIONS
AND
SKILLS
(licenses,
certificates,
office

equipment)




     
     
      
      
       
 
        
    
      
      
                
       




     
     
      
      
       
 
        
    
      
      
                
       



Were
you
referred
to
this
program?
 If
yes,
by
whom
     
      
                
       








                                          3





REFERENCES:

(List
two
persons
who
are
not
related
to
you
and
have
a
definite


         
 




knowledge
of

your
qualifications)




         
 
       
      
      
       
      
      
    
      
      
   

Name
 
     
       
      
      
       
      
      
    Phone


         
 
       
      
      
       
      
      
    
      
      
   

Name


     
       
      
      
       
      
      
    Phone





Have
you
ever
been
convicted
of
a
felony?
       







If
yes,


 
       
      
      
       
      
      
    
      
      
   


         
 (Date)

       
      
       
      (Location)



USE
THIS
SPACE
TO
TELL
WHY
YOU
WISH
TO
ENTER
THE
DENTAL
ASSISTING

PROGRAM.

ADD
ANY
ADDITIONAL
INFORMATION
ABOUT
YOURSELF
THAT

YOU
BELIEVE
WILL
GIVE
AN
INDICATION
OF
YOUR
INTEREST
AND
ABILITY
TO

PROFIT
BY
THE
EDUCATION
OFFERED.




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   




         
 
       
      
      
       
      
      
    
      
      
   



CERTIFICATION



I
certify
that
all
of
the
statements
made
in
this
application
are
true,
complete

and
correct
to
the
best
of
my
knowledge
and
belief,
and
are
made
in
good

faith.

I
also
promise,
if
accepted,
to
obey
all
rules
and
regulations
of
the

Dental
Assisting
Program
and
understand
that
the
program
reserves
the
right

to
compel
the
withdrawal
of
any
student
whose
conduct
at
any
time
is
not

satisfactory
to
the
UAB
School
of
Dentistry
or
the
Dental
Assisting
Program.




        
      
      
      
     
      
       

Signature
(in
ink)


        
      
      
      
     
      
       

Date


                                         4


								
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