GRADUATE DENTAL EDUCATION POSTDOCTORAL

2022-2023 Graduate Dental Education Program for ORTHODONTICS

Please complete the supplemental form as required by selecting the information from below form. Applicant must provide full legal name as it appears on his/her passport. If appropriate, please also provide maiden name in order to match application documents.

All correspondence will be sent to your current address listed on your PASS application. If you prefer other arrangements, please indicate your preferred mailing address below:

ADDITIONAL PROGRAM TO WHICH APPLYING

Note: Postdoctoral students who have completed an advanced clinical training program recognized by the ADA, at an accredited institution are eligible to apply for the Doctor of Science in Dentistry (DScD) program without certificate. To apply to the DScD program alone, see application instructions and procedures.

DENTAL EDUCATION
WORK EXPERIENCE

Do you have additional educational training/work history in the following areas? Check all that apply

ADDITIONAL INFORMATION

    1. Has your education ever been interrupted or affected adversely for reasons other than deficiencies in conduct or academic performance? If yes, please describe.(Five-Hundred word limit per response, single line space.)

    2. Have you ever been disqualified, suspended, dismissed, or otherwise subject to disciplinary action at any college or university in connection with your academic performance? If yes, provide an explanation regarding each disqualification, suspension, dismissal, or disciplinary action. Include 1) a brief description of the situation, 2) the specific charge(s) made, 3) the disciplinary action taken, and 4) a reflection on the experience and how the experience has affected your life.(Five-Hundred word limit per response, single line space.)

    3. Have you ever been found to have violated a school rule, policy or procedure, or an honor code; or have you otherwise been disqualified, put on probation, suspended, dismissed, expelled, or otherwise been subject to disciplinary action at any college/university in connection to misconduct? Please include any and all instances of misconduct, regardless of whether the school maintains a record of such misconduct or formal action, or whether it appears on your transcript. If yes,provide an explanation regarding each violation. Include 1) a brief description of the incident, 2) the specific charge(s) made, 3) the disciplinary action taken, and 4) a reflection on the experience and how the experience has affected your life.(Five-Hundred word limit per response, single line space.)

    4. Are you currently under charge or have been convicted of a felony and/or misdemeanor? If yes, provide an explanation. Include 1) a brief description of the incident and/or arrest, 2) the specific charge made, 3) related dates, 4) consequences, and 5) a reflection on the incident and how the incident has impacted your life.(Five-Hundred word limit per response, single line space.)

    5. Have you ever been denied professional licensure; had a professional license revoked or suspended; or have been subject to disciplinary action by any licensure board or agency? If yes, please provide the dates and details.(Five-Hundred word limit per response, single line space.)

    6. Postdoctoral students interact with patients from many backgrounds. Other than English, indicate any languages in which you feel comfortable conversing with native speakers:(Five-Hundred word limit per response, single line space.)

    7. What qualities of Penn Dental Medicine’s postgraduate program do you feel will help you achieve your professional goals and how? (One-thousand word limit per response, single line space.)

Postdoctoral students applying to the DScD program concurrent with an advanced dental education program, must also submit a one-page statement indicating their interest in the combined program and their research interests that can serve as a basis for DScD research planning. In addition, applicants must submit a biographical sketch in NIH bio-sketch format (see sample online). A resume or curriculum vitae is not an acceptable substitution for the Biosketch. Please attach the NIH Biosketch to the GDE Supplemental Application.

CAPTCHA/CERTIFICATION –– PLEASE READ AND AGREE CERTIFICATION BELOW

I hereby certify that I provided accurate information in this application. I understand and agree that any misrepresentation or omission of facts in my application will justify the denial of admission, the cancellation of admission, or expulsion. I also understand that students in certain programs are required to undergo a Criminal Record Check and Child Abuse History Clearance in order to treat minor students in the Commonwealth of Pennsylvania. I also understand that I will be responsible for payment of such fees.

• The University of Pennsylvania values diversity and seeks talented students, faculty and staff from diverse backgrounds. The University of Pennsylvania does not discriminate on the basis of race, color, sex, sexual orientation, gender identity, religion, creed, national or ethnic origin, citizenship status, age, disability, veteran status or any other legally protected class status in the administration of its admissions, financial aid, educational or athletic programs, or other University-administered programs or in its employment practices. Questions or complaints regarding this policy should be directed to the Executive Director of the Office of Affirmative Action and Equal Opportunity Programs, Franklin Building, 3451 Walnut Street, Suite 421, Philadelphia, PA 19104-6106; or (215) 898-6993 (Voice).

• The federal Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, as amended, requires colleges and universities to provide information related to security policies and procedures and specific statistics for criminal incidents, arrests, and disciplinary referrals to students and employees, and to make the information and statistics available to prospective students and employees upon request. Federal law requires institutions with on-campus housing to share with the campus community an annual fire report. In addition, the Uniform Crime Reporting Act requires Pennsylvania colleges and universities to provide information related to security policies and procedures to students, employees and applicants; to provide certain crime statistics to students and employees, and to make those statistics available to applicants and prospective employees upon request.

You may view the report here or request a paper copy of the report by calling the Division of Public Safety’s Office of the Vice President a 215-898-7515.

If you have any questions regarding the admissions process, contact (215) 898-5792 or (215) 898-8943 M-F from 9:00 a.m. through 4:30 p.m. or PDMGDE-Admissions@upenn.edu.
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