| Page 7 | Temple University Kornberg School of Dentistry

Termination of Privileges Form

FIRST NAME *

LAST NAME *

TUId *

9-digit TUId

Year of Graduation *

20XX

PERMANENT ADDRESS - STREET *

Permanent Address - State *

Preferred Address - Street, City, State, Zip

Leave blank if same as permanent address

PRIMARY PHONE *

PRIMARY EMAIL *

Employment Plans After Graduation *

TERMINATION OF PRIVILEGES

Digital Signature *

Upon electronically signing this form, you are requesting that the Office of Academic Affairs terminate your privileges at the Kornberg School of Dentistry upon graduation.

Leave this field blank

12/9

Friday

Lunch and Learn with Protective Life Insurance Company

1/11

Wednesday

Dental Microscopes: Evolution and Ergonomics in the Dental Operatory

12/2

Friday

Life Before and After Dental School (Lunch and Learn)

Endo Residency Application Process

Asian American Dental Student Association (AADSA)

11/1

Tuesday

Diwali Banquet, Banquet with Cultural Performances

Kornberg School ofDentistry

Termination of Privileges Form

Pages

Kornberg School of
Dentistry