| Page 6 | Temple University Kornberg School of Dentistry

First Name *

Last Name *

Preferred Pronouns *

he/him/his"

she/her/hers"

they/them/theirs"

I do not want to provide preferred pronouns"

Preferred Email *

Phone *

Earliest Program Deadline *

Month

Day

Year

Year of Graduation *

Month

Day

Year

Are you applying for post-doctoral programs? *

Yes

No

If you checked "other" in response to the last question, please specify below what program or programs you are applying to.

Do you require sealed copies of your letter to send to non-PASS programs? *

Yes

No

If yes, please provide the program(s)'s addresses and the number of copies required.

Does the program permit an emailed copy of your letter?* *

Yes

No

If yes, please provide the program's email address.

Digital Signature *

By requesting an Institutional Evaluation Form (IEF), I give consent to release my academic and disciplinary information to those persons or places requesting information, in writing or online, for the purpose of the IEF for post-graduate programs. I authorize Temple to release my records and make this release understanding my right to prevent disclosure of information from my educational records under the United States Family Educational Rights and Privacy Act of 1974. This authorization and consent expires one year from the date of this signature unless otherwise revoked in writing addressed to Temple University at dentalacademics@temple.edu.

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Kornberg School of
Dentistry

TUKSOD Institutional Evaluation Form

Pages

Kornberg School ofDentistry

TUKSOD Institutional Evaluation Form

Pages

Kornberg School of
Dentistry