University of Texas Health Science Center at San Antonio (UTHSCSA) School of Dentistry International Dentist Education Program (IDEP) 7703 Floyd Curl Drive, Mail Code 7897 San Antonio TX 78229 Phone: (210) 567-1411 Email: [email protected]

2017 IDEP APPLICATION CHECKLIST (Applications will only be accepted from August 1 through October 31, 2016) NOTE: All supporting documents are to be submitted with the IDEP application and received by the deadline date of October 31, 2016. COMPLETED APPLICATION PACKET Submit a fully completed application packet with all forms signed and dated by the individual apply to the program. Supporting documents are to be submitted with the application. APPLICATION FEE A nonrefundable application fee of $150 US dollars must be submitted with the application. A cashier’s check or money order for the application fee should be payable to UTHSCSA School of Dentistry – IDEP. DENTAL EDUCATION, EXPERIENCES, RELATED ACTIVITIES, PROFESSIONSAL GOALS Submit an updated Curriculum Vitae (CV). FOREIGN DENTAL DEGREE (DIPLOMA) Submit an official school certified or U.S. notarized copy of applicant’s foreign dental diploma. If the diploma is in a language other than English, it must be accompanied by a U.S. certified English translation. DENTAL SCHOOL TRANSCRIPT Submit official school certified dental school transcripts with the school seal in a sealed envelope from the dental school. If the transcripts are in a language other than English, they must be accompanied by a U.S. certified English translation. Notarized copies are not accepted. COURSE-BY-COURSE SCHOOL TRANSCRIPT EVALUATION Submit an original ECE “course-by-course” evaluation of the applicant’s foreign dental school transcripts in the sealed envelope from Educational Credential Evaluators, Inc. A minimum U.S. GPA of 2.50 or above is required. NATIONAL BORAD DNETAL EXAINATION – Part 1 Submit an original score report of the applicant’s National Board Dental Examination in the sealed envelope from the American Dental Association. An NBDE Part 1 “status” of PASS is required. If the NBDE has been taken or will be taken by the applicant, scores must be received by the deadline date of October 31, 2016. TEST OF ENGLISH AS A FOREIGN LANGUATE (TOEFL) Submit an original score report of the applicant’s TOEFL examination (IBT format) in the sealed envelope from the Educational Testing Service (institution code 0345, undergraduate). The TOEFL test must be no more than 2 years old a minimum score of 92 is required. LETTERS OF RECOMMENDATION Submit 3 official, original letters written in English in the original sealed envelope from the author of the letter. Letters should be no more than 12 months old. PERSONAL PHOTOGRAPHS Submit 2 recent passport size photographs of the applicant, signed and dated on the back by the applicant. REFERENCES: 1. Course-by-Course transcript evaluation: Educational Credential Evaluators, Inc. (ECE) 2. National Dental Board Examination: American Dental Association, Joint Commission on National Dental Examinations 3. TOEFL examination: English Testing Service. (ETS)

FOR OFFICIAL USE ONLY UTHSCSA IDEP Application 2017 IDEP Application received on _____________ Application fee received _____________


Last Name _____________________________ First Name __________________________Middle Name __________________________


Other Name (list any other name that appears on documents) _____________________________________________


Preferred Name (name you would like to be called) ______________________________________________________


Gender Male _____


Date of Birth _____/_____/_____Place of Birth ___________________________ __________________________ City Country U.S. Social Security Number _____-_____-_____ *Please see Notice of Request of SSN provided with this application form.


Female _____

Marital Status

Single _____

Married _____

CONTACT INFORMATION (Provide permanent address if different from current address.) 7.

Current Mailing Address ___________________________________________________________________________ City ____________________________________

State/Providence ________________________________

Country _________________________________

Postal Code _____________________________________

Current Telephone (_____) _________________

Cell/Work (_____) ________________________________

Email ___________________________________ 8.

Permanent Mailing Address (if different from above address) _____________________________________________ City ____________________________________

State/Providence ________________________________

Country _________________________________

Postal Code _____________________________________

Current Telephone (_____) _________________

Cell/Work (_____) ________________________________

Email ___________________________________ CITIZENSHIP INFORMATION (Please indicate if U.S. Citizen, provide your SSN on line #6) 9. 10.

U.S. Permanent Resident


No _____

Alien Registration Number __________________________ Expiration Date __________

Country of Citizenship ______________________________________________

VISA INFORMATION 11. Do you hold a United States Visa

Yes _____ No _____

Visa Status (please circle which applies)




Other ___________

Expiration Date _________

ETHNICITY INFORMATION (Completion of this section is optional. For data collections purposes, please check only one.) 13. Native American ________

African American (not of Hispanic Origin) ________

White, not of Hispanic Origin ________

Mexican American ________

Other Hispanic _____________________________________________

Asian or Pacific Islander _______

Puerto Rican ________

Cuban _______

EDUCATIONAL HISTORY 14. List education starting with Dental School, include all post graduate education. Full name of Institution

Location of Institution (City, Country)

Date Entered (Month/Year)

Date Withdrew (Month/Year)

Course of Study

Degree Earned

Degree Earned (Month/Year)

If you have ever been dismissed from any college, graduate school, or professional school, attach an explanation on a separate sheet. DATES OF EXAMINATIONS 15. Test of English as a Foreign Language (iBT TOEFL)

Date (Month/Year) _______________ Total Score _______________

16. National Dental Board Examination, Part 1

Date (Month/Year) _______________ Total Score _______________

17. National Dental Board Examination, Part 2

Date (Month/Year) _______________ Total Score _______________

STATISTICAL INFORMATION 18. Have you ever been licensed in any country as a dentist?

Yes _____

No _____

License #_______________ Date Issued ____________

19. Have you ever had any disciplinary action taken against you and/or revocation of your foreign dental license? Yes _____ (If yes, attach an explanation on a separate sheet.) 20. What is your native language? __________________________________ 21. Language(s) other than English __________________________________

Speak _____

Read _____

Write _____


Speak _____

Read _____

Write _____

22. How many years have you studied English? ____________

No _____

In which country did you study English? ________________________________

23. How did you hear about the UTHSCSA International Dentist Education Program? __________________________________________________

Please sign and date this application and send the application with the fee and supporting documents to: UTHSCSA - International Dentist Education Program (IDEP) ATTN: Barbara Sturm 7703 Floyd Curl Drive, Mail Code 7897 San Antonio TX 78229 United States I certify that the information given in this application is accurate and complete to the best of my knowledge. I understand that I am responsible for insuring that any required document are forwarded to the International Dentist Education Program office and are received by the deadline date of October 21, 2016. I understand that the information I have provided is true and correct and any falsification of my application or irregularities of Records are grounds for an immediate cancelation of my application or enrollment and dismissal from the UTHSCSA IDEP School of Dentistry.

Applicant’s Signature __________________________________________________________

Date Signed _______________________________

NOTE: Once application documents are received by this IDEP office, they become the property of the UTHSCSA School of Dentistry.

We would like to know more about you and how we can best serve our students. In the past we asked candidates for a personal statement but often it was difficult for candidates to know what to write and the personal statement ended up being a synopsis of their CV. This did not give opportunities for candidates to show who they are as a person and to think through what they want in a program. We have changed the personal statement section and are asking you to briefly answer a few questions that will help us to get to know who you are and what you are passionate about. There is no right or wrong answers. The goal is to let us hear about you and your preferences. Answer the following questions on separate paper.

1) What is your ideal dental school environment? Be specific, do you like to work alone, in groups, with lots of faculty support or do you prefer to work more independently with faculty feedback. Do you like busy environments or do you prefer a quieter setting? What interests you? What are you looking to gain in your U.S. education? Share your ideas, feel free to be you! (200 words or less)

2) What is the most stressful situation you have encountered in dentistry? How did you handle the situation? Be specific, give good details to Help us understand why the situation was stressful and what your personal style is in working through the natural stress of dentistry. Please tell us your thoughts or advice on dealing with the stress. (200 words or less)

3) What drives you to succeed both personally and professionally? What motivates you in your career and personal life? Be specific, explain why and give examples on how this drive has caused you to achieve. (200 words or less)

4) What types of people annoy you the most and how do you deal with them? If you were giving our best friend or family member advice on difficult people what would that be? (200 words or less)

5) Give an example of how you solved a clinical problem. It can be about a patient issue, a work place situation or dental school issue. (200 words or less)

6) Would others say you are organized and the type to plan ahead or more of a free spirit who prefers to handle thing as they happen. Make a compelling argument for why your style works for you, examples. (200 words or less)

UTHSCSA School of Dentistry IDEP Applicant’s Report of Formal Records

The University of Texas Health Science Center School of Dentistry requests that all applicants to the International Dentist Education Program provide information concern any past felony or misdemeanor records. While the record of conviction would not necessarily prevent an applicant from being accepted or enrolled at the School of Dentistry, failure on the part of an applicant to provide information concerning such conviction would prevent matriculation or result in dismissal from the educational program if the information were later revealed, thus indicating that the applicant had falsified the report of formal records. In order to comply with this request, please sign below on this form after correctly answering the question. Thank you for your compliance with this request. We are pleased that you are an applicant to the University of Texas Health Science Center School of Dentistry for the International Dentist Education Program. As requested, you must answer the following question by placing your initials in the space provided next to either “yes” or “no”. You must then sign and submit this report of your formal records with your IDEP application packet.

Have you ever been convicted of a felony or misdemeanor other than traffic violations? Yes __________

No __________

If you answered “yes” to the above question, please attach a statement of explanation to this report of your formal records.

I hereby certify that to the best of my knowledge the information above is true and complete. I understand that if found to be otherwise, it is sufficient cause for possible rejection or dismissal at the University of Texas Health Science Center School of Dentistry.

Printed Name of Applicant ___________________________________________________ Signature _______________________________________________Date ______________

UTHSCSA notice for Request of Social Security Number for Student Application Process

Disclosure of your Social Security Number is requested for the student records system of The University of Texas Health Science Center at San Antonio and for compliances with Federal and State reporting requirements. Federal law required that you provide your SSN if you are applying for financial aid. Although a SSN is not required for admission to the University, failure to provide your SSN may result in delays in processing your application or in the University’s inability to match your application with transcripts, test scores and other materials. Students SSNs are maintained and used by the University for criminal background checks, financial aid, internal verification and administrative purposes and for reports to Federal and State as required by law. Law protects the privacy and confidentiality of student records and the University will not disclose your SSN without your consent for any other purposes except as allowed by law. In accordance with Section 559.003(a) of the Texas Government Code, with few exceptions, the individual is entitled on request to be informed about the information that the institution collects about the individual, under Sections 551.021 and 552.023 to receive and review information, and under Section 559.004 to have the instution correct information about the individual that is incorrect.