DMD-PhD Application Instructions Current DMD Student

Below is a list of all documents required for review by the DMD-PhD Admissions Committee of the

University of Florida. Follow the instructions for submission of each set of documents.

• DMD-PhD Application Form. Print and submit the signed paper document or email a pdf of the

scanned and signed document.

• A Curriculum Vitae following the “Application Curriculum Vitae Template”. Print and submit

the signed paper document or email a pdf of the scanned and signed document.

• Letters of Recommendation and Release Forms. Three letters of recommendation are requested

from faculty that have either mentored you in your current or previous research, or are familiar

with your research. If you are a current student in semesters 6 or 7, one of your letters may be

from a faculty member of the UF COD that can attest to your clinical abilities and time

management skills. For each reviewer, fill out the top half of the “UF Graduate School

Recommendation Letter” form and also complete the “Release for Letter of Recommendation”

form. Print and sign both forms and distribute to each reviewer.

• Copies of all transcripts; Undergraduate, DMD and any other Graduate transcripts (Official

transcripts are not necessary at this time)

• Dean’s Certification Form and any Accompanying Letters. Fill out the top half of the form, sign

and submit to the COD Office of Education. The Office of Education will forward the

completed form to the DMD-PhD Coordinator. Note: If you have accepted a position in the

DMD program but have yet to start the 1st semester, you do not have to submit these documents.

Submission: Either email completed and signed pdf documents to dculp@dental.ufl.edu with “DMD-

PhD Application” in the subject line or mail to Dr. David Culp, DMD-PhD Coordinator, College of Dentistry, PO BOX 100424, Gainesville, FL 32610

Note: If you are offered a position in the DMD-PhD program you will be required to submit your

official transcripts and DAT scores, if not already received by the DMD-PhD Admissions Committee.

These documents are in addition to those sent previously for admission to the DMD program. The

official documents are to verify self-reported scores and for files in the DMD-PhD program in the

College of Dentistry and in the Interdisciplinary Program in Biomedical Sciences.

1

University of Florida DMD-PhD Application Form: Current DMD Student Application Submission Date (MM/DD/YYYY):

Last Name First Name Middle Name(s)

Gender UFID Date of Birth (mm/dd/yyyy) Email

Cell phone: Daytime phone: Evening phone:

Current Address Street State

City Country Postal/Zip Code

Permanent Address

Street State

City Country Postal/Zip Code Year Started DMD Program:

IDP Program of Concentration:

Letters of Recommendation

Recommender #1: Name Title Institution Affiliation

Email: Phone: Recommender #2: Name Title Institution Affiliation

Email: Phone: Recommender #3: Name Title Institution Affiliation

Email: Phone: Education Information

College Name Degree Earned

Location Dates

Attended

2

Residency Information Are you a bona fide Florida resident? Yes No If yes how many years have you been a Florida resident?

Are you a United States citizen? Yes No Are you a Permanent Resident of the United States? Yes No If yes, how many years have you been a United States citizen?

If foreign where were you born?

If foreign what is your citizenship?

How many years have you been in the US?

Race/Ethnicity (please check all that apply) I am Spanish/Hispanic/Latino/Latina I am NOT Spanish/Hispanic/Latino/Latina American Indian or Alaskan Native Native Hawaiian or Pacific Islander Asian White Black or African American

3

Personal Statement Use this space to inform the admissions committee of your career goals and of your previous research experiences. Address how your research experiences influenced your goals. Provide any other information you wish to convey. Limit to the text boxes on this and the following page.

4

5

Conduct Disclosure 1) Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to a crime in any jurisdiction, other than a minor traffic offense? (You must include all misdemeanors and felonies, even if adjudication was withheld by the court or even if the records were expunged so that you would not have a record of conviction.) Yes No 2) Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to driving under the influence or driving while impaired? (You must include all misdemeanors and felonies, even if adjudication was withheld by the court or even if the records were expunged so that you would not have a record or conviction.) Yes No If you answered yes to Questions 1 or 2, please list date, jurisdiction (state and county), offense, disposition, and all other relevant information within the confines of the box below. 3) Have you ever been charged with or subject to disciplinary action for academic or any other type of misconduct at any educational institution? Yes No If you answered yes to Question 3, include a full statement of the relevant facts within the confines of the box below

6

Checklist and Information Release Checklist To the applicant: Below is a list of all documents required for review by the DMD-PhD Admissions Committee of the University of Florida. The DMD-PhD Admissions Committee will maintain strict confidentiality of all documents received. If you are accepted into the DMD-PhD program these documents will be entered into the DMD-PhD Program files in the College of Dentistry and in the Interdisciplinary Program in Biomedical Sciences in the College of Medicine.

• DMD-PhD Application Form • Curriculum Vitae • Letters of Recommendation • All Official Undergraduate, DMD and any other Graduate Transcripts • Official DAT scores • Dean’s Certification Form

Information Release

I hereby authorize upon my acceptance into the DMD-PhD Dual Degree Program at the University of Florida the release of all documents required for the DMD-PhD admissions process to both the DMD-PhD Program of the College of Dentistry and to the Interdisciplinary Program in Biomedical Sciences in the College of Medicine.

Last Name First Name Middle Name(s)

Applicant Signature (Required) Date (mm/dd/yyyy) Privacy Statement The University of Florida College of Dentistry and the Interdisciplinary Program in Biomedical Sciences in the College of Medicine takes all of the necessary technical and organizational security measures to protect your personal data from being lost or misused. For instance, your data is saved in a secure operating environment that is not accessible to the public and backed up on a regular basis on and off site. Although we take steps to protect personally identifiable information you provide to us via email from loss, misuse, or unauthorized alteration, no system is 100% secure or error-free. Therefore, we do not, and cannot, guarantee the security or accuracy of the information we collect via email, and you acknowledge that you are assuming the risk in transmitting any information to us. For information about the UF Information Privacy Statement, please visit www.privacy.ufl.edu/informationprivacy.html Submission Submission: Email a signed copy of this form in pdf format to dculp@dental.ufl.edu with “DMD-PhD Application” in the subject line or mail to Dr. David Culp, DMD-PhD Coordinator, College of Dentistry, PO BOX 100424, Gainesville, FL 32610

CURRICULUM VITAE First Name, Last Name RESEARCH POSITIONS From Month/Year – Position, University/Company, Laboratory, Project, Name of PI. To Month/Year HONORS and AWARDS Year Title of Award TEACHING and SUPERVISORY EXPERIENCE From Month/Year – To Month/Year University/College/School CERTIFICATIONS and TRAINING TEST SCORES DAT score and date taken: GPA - Undergraduate: TOEFL score (if applicable): TECHNICAL/LABORATORY SKILLS PUBLICATIONS POSTERS ORAL PRESENTATIONS COMPUTER KNOWLEDGE LANGUAGES

UNIVERSITY OF FLORIDA GRADUATE SCHOOL�RECOMMENDATION LETTER�

To the applicant: This form is to be filled out by a professor or supervisor under whom you have studied, taught or worked, and who is able to

comment on your qualifications for graduate study. Please fill in the first section of this form online or print neatly in the fields below.

Applicant UFID (if known) Applicant Last Name Applicant First Name Applicant Middle Name

Applicant Address

Major Department Degree Goal

Name of Recommender Title Institution or Enterprise

If you are admitted to the University of Florida, you have the right, as a student, to review your permanent record, including this recommenda-

tion form, on file with the university. Some people prefer not to complete recommendation forms unless they can be assured of the confidenti-

ality of their comments. It is our opinion that comments provided on a confidential basis are likely to be more helpful to us in judging important

characteristics such as creativity, originality, independence and research capability. Therefore, the university is affording you the opportunity to

waive your right of subsequent access to this recommendation letter form. In any event, your application for admission and/or financial support

will be given full consideration based on all the information accumulated in your application file, including this form, regardless of your decision

on waiving your right of future review.

Do you waive your right of subsequent access to this recommendation letter form? Yes No

__________________________________________________________________________________________________________________________________________________

APPLICANT SIGNATURE DATE

TO CLEAR ALL ENTRIES ABOVE AND RESET THIS FORM, CLICK HERE.

To the recommender: Please rate the applicant with others of the same age and academic level. It is important to the applicant that you give

a percentage rating on the grid below as well as a written evaluation. If you are not able to judge in any category, please explain why.

LOWER

THIRD

MIDDLE

THIRD

UPPER

THIRD TOP 10% UPPER ____%

NOT ABLE

TO JUDGE

Competence in his/her chosen field

Motivation and diligence

Creativity or research potential

Intellectual ability and critical thinking

Potential as a teacher

Emotional maturity

Please provide a written evaluation of the applicantYs suitability as a graduate student. How long have you known the applicant, and in what

capacity? (Attach as a letter typed on letterhead.)

__________________________________________________________________________________________________________________________________________________

RECOMMENDER SIGNATURE DATE

PLEASE MAIL THIS FORM �����!!��������!!���DIRECTLY TO���/,,')'�/(��'.2+1206���((+%'�/(��&-+11+/.1������/5����������$+.'14+,,'������ ������������������ ���������������� �!������$&-+11+/.1�&'.2$,�3(,�'&3�#�!��������*����������!��� "����!������� �

Revised 20 September 2004

Instructions for Faculty: School officials may use this form when a student requests them to write a letterof recommendation. A signed release from a student is necessary to obtain written consent from the student.Student consent should include: (1) the data to be disclosed, (2) to whom the data will be disclosed, and(3) the student’s signature and date.

Nondirectory information should not be included in a letter of recommendation without the student's writtenconsent. Examples of nondirectory information include: birth date, religion, citizenship, disciplinary status,ethnicity, gender, GPA, marital status, UFID or social security number, grades/exam scores and standardizedtest scores.

If a letter of recommendation contains nondirectory information:• A written release is recommended, not required, for recommendations sent to other educational

institutions in which the student seeks to enroll, including professional school admission services.• A written release is required for general letters of recommendation sent to an employer or an individual.

Instructions for Students: Complete, sign and return to the faculty member.

I give my permission to to write a letter of recommendation to: (Name of faculty member)

(Name of person, business, institution or service)

(Address)

(City, State, Zip)

I give my permission to include the following nondirectory information in this letter of recommendation: Grades GPA Other (please identify)

I waive my right to review this recommendation letter: I waive I do not waive

Student signature Date

Release forLetter of Recommendation

Rev. 7/07

DMD/PhD Admissions College of Dentistry

PO BOX 100445 Gainesville, FL 32610-0445

(352) 273-5955

DMD/PhD Admissions Dean’s Certification Form

To the applicant: Complete the spaces below and sign this form. Submit this form to the Associate Dean for Education at the University of Florida College of Dentistry. The DMD/PhD Admissions Committee will maintain strict confidentiality of this document and all associated materials requested below. Name: _______________________________________________________________________________________ First Middle Last Current Address: _______________________________________________________________ UFID __________ Number and Street _____________________________________________________________________________________________ City and State Zip Code Current Telephone E-mail

WAIVER OF ACCESS AND RELEASE OF TRANSCRIPTS I have requested that this certification form be completed for the use in the admissions process to the DMD/PhD Dual Degree Program at the University of Florida. I hereby authorize release of this information to the DMD/PhD Admissions Committee of the University of Florida.

I waive access to this form. I do not waive access to this form. The results of this questionnaire will be made available to a student who

has not agreed to this waiver. REQUIRED: I authorize release of my UF COD Transcript to the DMD/PhD Admissions Committee.

_____________________________________________________________ ________________________ Applicant Signature Required Date (mm/dd/yyyy)

To be completed by the UF COD Associate Dean of Education

Please answer the following questions:

• Is this individual in good standing regarding conduct in the DMD Program? If no, please attach an explanation.

Yes No

• Has this individual been the subject of conduct-related disciplinary action, proceedings, suspension or probation? If yes, please attach an explanation

Yes No

• Please fill out the table below regarding applicable GPA’s and rankings for this individual.

Ranking Class Size GPA

1st Year

2nd Year

3rd Year

Cumulative to Date

• Please fill out the table below regarding scores for this individual on National Board Dental Examination, Part 1. If exam not taken to date, indicate NA under exam date.

Exam Date Anatomic

Sciences

Biochemistry Physiology

Microbiology Pathology

Dental Anatomy Occlusion

STD. Score

Scores

• In the space below please give overall evaluation of this applicant. • Please sign this form and submit along with all attachments to the UF COD Office of Admissions, care of

DMD/PhD Admissions. ___________________________________________________________ Name ________________________________________________________ ____________________________ Signature Date