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  Application for Admission

School of Orthodontics 

 Instructions to Admission Applicants

Complete and submit this supplemental application directly to JacksonvilleUniversity 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. A pplication fee ($100.00)

4. 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.

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School of Orthodontics

 Application for AdmissionSchool of Orthodontics

 

Jacksonville University

2800 University Blvd NorthJacksonville, 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_______________________________________

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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 beenexpunged 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)

 _________________________________ Telephone Number ( ) _________________(Relationship to Applicant)

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

Date: _______________________________ Signed: _________________________________