Application for Admission

School of Orthodontics
Instructions to Admission Applicants
Complete and submit this supplemental application directly to Jacksonville
University School of Orthodontics in addition to the required materials requested
through PASS.
1.

A recent photograph (2x2 or 3x5).

2.

Mail your supplemental application package to:

School of Orthodontics
Jacksonville University
2800 University Blvd North
Jacksonville, FL 32211
(904) 256-7847

3.
4.

Application fee ($100.00)

Select which program/ programs that you are applying for:
1 year Full-Time Fellowship in Orthodontic Clinical Research
2 year Certificate in Orthodontics
3 year Certificate in Orthodontics combined with a Masters in Education *
3 year Certificate in Orthodontics combined with a Masters in Business Administration *

*Application fee in only for the School of Orthodontics. Other application fees may apply
to the School of Education and/or the College of Business.

Application for Admission

School of Orthodontics
School of Orthodontics
Jacksonville University
2800 University Blvd North
Jacksonville, FL 32211
NAME_______________________________________________________________________
(Last/Family Name)
(First Given Name)
(M.I.)
_______________________________________________________________________
(Previous Names(s) if any)
SOCIAL SECURITY NUMBER__________________________________________________
CELLULAR TELEPHONE NUMBER (___) _______________________________________
(Check if none )
MAILING ADDRESS

_________________________________________________________
(Number and Street)

(Apartment or Box Number, if any)

_________________________________________________________
(City)
(State)
(Zip Code)
_____________________ Telephone Number (___) ______________
(Country if not US)
(Check if none )
E-Mail Address________________________

FAX Number (___) ___________

PERMANENT ADDRESS_______________________________________________________
(Check here if same
(Number and Street)
(Apt or Box #, if any)
as mailing address )
________________________________________________________
(City)
(State)
(Zip Code)
________________________Telephone Number (___) ___________
(Country if not United States)
(Check if none )
BIRTHDATE__________________________________________________________________
(Month / Day / Year)
GENDER

Male

Female

MARITAL STATUS

Single

Married

Other

CITIZENSHIP Print country of citizenship; if a United States Citizen, print USA: ________
Check here
if a Resident Immigrant (i.e. a green card holder)
Check here
if a Non-Resident Immigrant and indicate type of visa number
held, if any_______________________________________

ETHNIC ORIGIN
(U.S. Citizens and Residents Immigrants, check one box)
American Indian or Eskimo
Asian/Oriental or Pacific Islander
International
Black, Non-Hispanic
Hispanic American
White, Non-Hispanic
Academic term for which you are applying. _________
Have you previously applied to JU?

Yes

No If yes, when? _________________

How did you learn about the Orthodontic Program at Jacksonville University?
______________________________________________________________________________
Have you made application to orthodontic programs at other universities? If so, which one(s)?
______________________________________________________________________________
______________________________________________________________________________
List the states in which you currently hold a dental license or have held one in the past:
______________________________________________________________________________
If you have ever been employed as a dentist, list such employment:
______________________________________________________________________________
______________________________________________________________________________
Have you ever been convicted in any state or country of a criminal offense, other than a minor
traffic offense, where you have been found guilty by a judge or jury, or entered a plea of guilty or
nolo contendere (no contest), any juvenile offenses; any offenses where the records have been
expunged and any conviction that the applicant is currently appealing, regardless of adjudication?
Yes
No If yes, please explain ________________________________________________
______________________________________________________________________________
Emergency Contact _____________________________________________________________
(Last Name)
(First Name)
(Salutation/Title)
_________________________________
(Relationship to Applicant)

Telephone Number (

) _________________

I, as the applicant, attest that the information provided above is, to the best of my knowledge,
accurate and true.
Date: _______________________________

Signed: _________________________________