HS-MACA POST-BACCALAUREATE APPLICATION SYSTEM

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Program of interest:

Post Bac Pre-Dental Program

Post Bac Pre-Medical Program

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AADSAS ID Number

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AMCAS ID Number

4

Applicant's Name

First Name

Middle Name (Optional)

Last Name

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Phone

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E-mail Address

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Date of Birth(YYYY-MM-DD)

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Mailing Address

Street Address

Street Address Line 2

City

State

Zip Code

Country

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Sex

Male

Female

Decline to Answer

10

Are you Hispanic or Latino?

Yes

No

Decline to Answer

12

Emergency Contact

Name of Emergency Contact

Phone contact of Emergency Contact

Relation to Emergency Contact

13

College Expenses | Work History Please estimate the percentage of your college expenses paid from your:

Employment (USD)

Scholarships (USD)

Loans (USD)

Sponsorship (USD)

Did you work while in College?

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How many hours per week?

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Language(s) Spoken* This field is required.Select all that applies

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Other Language(s)

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In what type of community were you brought up? Select and add all that applies to you

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Questionnaire Results-DentalConditional Computation-Dental

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Questionnaire Results-MedicineConditional Computation-Medicine

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Please explain why you consider yourself educationally disadvantaged.

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Please explain why you consider yourself educationally disadvantaged.

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If you have been placed on probation, suspended or dropped from any educational institution for any reason, please explain fully.

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If you have been placed on probation, suspended or dropped from any educational institution for any reason, please explain fully.

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If you have ever been convicted of a crime other than a minor traffic violation, please explain fully.

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If you have ever been convicted of a crime other than a minor traffic violation, please explain fully.

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DAT Scores | GPA

DAT Scores - Academic Average (AA)

DAT Scores - Total Science (TS)

Number of times you have taken DAT

Science GPA

Overall GPA

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MCAT Scores | GPA

MCAT Scores - Total Scores (TS)

MCAT Chemical & Physical Foundations of Bio. Systems

Number of times you have taken MCAT

MCAT Critical Analysis and Reasoning Skills Score

Commulative GPA

MCAT Bio. & Biochemical Foundations of Living Systems

Science GPA

MCAT Psychological, Social, & Bio. Foundations of Behavior

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File UploadsPlease upload the following documents: 1. AADSAS Application 2. Photo of yourself (for identification)

Drag and drop files here

Select files to upload

1. AADSAS Application 2. Photo of yourself (for identification only)

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File Uploads* This field is required.Please upload the following documents: 1. AMCAS Application 2. Photo of yourself (for identification)

Drag and drop files here

Select files to upload

1. AADSAS Application 2. Photo of yourself (for identification only)

32

Please provide the Committee on Admissions with a statement about your future goals as they relate to the Post-Baccalaureate Program in Dentistry and your career in dentistry. It is helpful to the Committee if you can discuss the reasons for your interest in the program and how you expect the program to help you become successful in your pursuit of the practice of dentistry. Please address the strategies used to balance work and your educational activities, the ethnic communities you described above and provide an explanation on why you consider yourself economically disadvantaged.

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Background Investigation Policy & Procedures

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I verify that I have read and understand the Background Investigation Policy and Procedures.

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I verify that I have read and understand the Technical Standards Policy. I understand that other medical schools have different technical standards.

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I certify with my e-signature that the information submitted on this form and on any separate sheets that I have enclosed (and signed) is truthful, complete and correct. I agree to provide if asked, any documentation to support and verify this information. If selected for this program, I agree to participate in the program in compliance with its rules and regulations.Enter your name to sign this form electronically.

e-signature

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Application Date

Date

Hour

Minutes

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AADSAS | AMCAS Application

YESNO

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Photograph

YESNO

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Transcripts

YESNO

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Reference Letters

YESNO