| Page 8 | Temple University Kornberg School of Dentistry

To be considered for the Dental Assisting Program, please fill and submit this form.

Fields with an asterisk (*) are mandatory.

Name:

First Name *

Last Name *

Middle Name

Former Name

Former First Name

Former Last Name

Former Middle Name

If any of your transcripts, test scores, etc. might arrive under any name other than those listed above, enter names here:

Name that might appear in transcripts

Current Address:

Street *

City *

State *

ZIP Code *

Email

Is your mailing address different from the address above? *

Yes, it is different

No, it is the same

Mailing Address (if different from Address provided above):

Street

City

State

ZIP Code

Phone Numbers:

Home Phone (include area codes)

Cell Phone (include area codes)

Work Phone (include area codes)

Emergency Contact:

Last Name

First Name

Middle Name

Street

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Relationship

Residency:

Are you a United States citizen or a permanent Resident or have permission to work in the United States? *

Yes

No

If not, what is your current immigration/visa status?

Are you 18 years of age or older? *

Yes

No

Prior Academic History:

have you received a high school diploma or equivalent? *

Yes

No

High School Name

Do you have any post-secondary education? *

Yes

No

Additional Degrees:

(1) Program

Name of the Program

Degree

Date of Completion

(2) Program

Name of the Program

Degree

Date of Completion

(3) Program

Name of the Program

Degree

Date of Completion

(4) Program

Name of the Program

Degree

Date of Completion

English Language Proficiency Test

There will be a required English Language Proficiency Test to evaluate communication skills at the grade nine high school level. After a review of your application and you meet other admission criteria you will receive instructions as to scheduling your test.

There will be no cost for taking the English Language Proficiency Test.

English Language Proficiency Test Release *

I agree to the release of the results of the English Language Proficiency Test to the Temple University Kornberg School of Dentistry

Availability

Commitment to be available full time for in person training *

Yes

No

If applicable, please list employment experiences beginning with the most recent:

Experience (1):

Name and full address of school or company

Employed from (date)

Employed to (date)

Type of employment

Full-Time

Part Time

Name and title of Supervisor

Phone

Position

Reasons for leaving the job

Experience (2):

Name and full address of school or company

Employed from (date)

Employed to (date)

Type of employment

Full-Time

Part Time

Name and title of Supervisor

Phone

Position

Reasons for leaving the job

Experience (3):

Name and full address of school or company

Employed from (date)

Employed to (date)

Type of employment

Full-Time

Part Time

Name and title of Supervisor

Phone

Position

Reasons for leaving the job

Experience (4):

Name and full address of school or company

Employed from (date)

Employed to (date)

Type of employment

Full-Time

Part Time

Name and title of Supervisor

Phone

Position

Reasons for leaving the job

Please complete below and indicate

The reason you wish to become a Dental Assistant
Any special qualities or characteristics that would be an asset if you are admitted to this Dental Assisting program

Statement *

Acknowledgement

Acknowledgement *

I certify that all the information provided on this form is complete and accurate. I understand that falsifying any part of the application will result in cancellation or admission and/or registration. If admitted, I will be governed by the rules and regulations of Temple University Kornberg school of Dentistry.

Date

Month

Day