Fillable Marquette BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM application

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Marquette BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM application

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  • 40 check-boxes
  • 220 other fields

Country of origin: US
File type: PDF

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1 | Page
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Name and Contact Information
Name:
First
Middle
Last
Preferred Name:
Permanent Address:
Street
City
State
Zip Code
Preferred Phone
(xxx-xxx-xxxx)
Email Address:
Birthdate:
What is your gender?
☐ Female
☐ Male
☐ Non
-binary/third gender
☐
Prefer to self-describe:
☐ Prefer not to say
Our institution does not discriminate on the basis of gender identity or expression. In order to track the effectiveness
of our recruiting efforts and ensure we consider the needs of all our applicants, please consider selecting the
description that suites you best. This is optional.
Academic Audit
Note: You should verify that you have all of the pre-requisite classes for the dental schools that you will apply to.
Submit Your Personal Statement (email to BMPD@marquette.edu) with the Application: This can be the
same statement submitted with your previous AADSAS application
2 | Page
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Personal Information
Are you a US citizen?
☐ Yes ☐ No
Have you served in the Armed Forces?
☐ Yes ☐ No
Colleges and universities are asked by groups, including the federal government, accrediting associations,
college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and
employees. In order to respond to these requests, we ask you to answer the following two questions
(optional).
Do you consider yourself to be of Hispanic/Latino origin?
☐ Yes ☐ No
Regardless of your answer to the prior question, please check one or more of the following groups in which
you consider yourself to be a member (optional).
☐ Asian
☐ Black or African American
Parent/Guardian
First Parent or Guardian
Relationship
Native American or Alas
ka Native
Parent’s Name
Native Hawaiian or Other Pacific Islander
Occupation:
Education (highest degree):
Second Parent or Guardian
Relationship:
Parent’s Name:
Occupation:
Education (highest degree):
Asian
White
3 | Page
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Educational Information: Please list all colleges and universities (including Marquette University) that you
have attended
School 1
Name:
State:
Date Attended From:
Month
Year
Date Attended To:
Month
Year
Number of Credits Earned:
Degree Received, if any:
Choose an item
School 2
Name:
State:
Date Attended From:
Month
Year
Date Attended To:
Month
Year
Number of Credits Earned:
Degree Received, if any:
Choose an item
School 3
Name:
State:
Date Attended From:
Month
Year
Date Attended To:
Month
Year
Number of Credits Earned:
Degree Received, if any:
Choose an item
4 | Page
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Honor Pledge and Signature, Application Fee
All students at Marquette will be expected to take the university's Honor Pledge and follow the Honor Code. Upon
entering Marquette you will be asked to abide by the Honor Code throughout your enrollment.
Honor Pledge
I recognize the importance of personal integrity in all aspects of life and work. I commit myself to truthfulness, honor
and responsibility, by which I earn the respect of others. I support the development of good character and commit
myself to uphold the highest standards of academic integrity as an important aspect of personal integrity. My
commitment obliges me to conduct myself according to the Marquette University Honor Code.
By signing this application, you acknowledge that all work submitted is your own.
In place of your signature, please type your full legal name.
$40 Application Fee: Submit check made payable to: Marquette University,
Attn: Dr. Judy Maloney, Marquette University, PO Box 1881, Milwaukee, WI
53201-1881 phone (414) 288- 7251; fax (414) 288-6564
or pay by credit card: Name on Card
Card Number
Exp. Date
CV Code
*Visa and MasterCard Only
5|Page
BIOMEDICALSCIENCESPRE‐DENTALPOST‐BACCALAUREATEPROGRAM(BMPD)
Background Information
Describe any activities requiring manual dexterity (e.g. activities requiring hand-eye coordination such as cross-
stitching, sewing, art, crafts, playing musical instruments, auto repair, etc.) at which you are proficient.
Do you have any relatives who are dentists, are in dental school, or who have studies or are studying Dental
Hygiene, Dental Assisting, Dental Laboratory Technology, or related dental fields?
☐ Yes ☐ No
If yes, indicate name, relationship, dental degree or certificate.
Have you ever applied to dental school (including Marquette University School of Dentistry)?
☐ Yes ☐ No
If yes, include the name of school to which you applied to and the year(s) of application. If accepted/enrolled,
indicate dates of enrollment.
6|Page
BIOMEDICALSCIENCESPRE‐DENTALPOST‐BACCALAUREATEPROGRAM(BMPD)
☐ Yes ☐ No
If you answered yes to this question, you must provide an explanation. Include: 1) a brief description of the incident, 2)
the specific charge(s) made, 3) related dates, 4) consequences and, 5) a reflection on the incident(s) and how the
incident(s) impacted your life.
Have you ever been disciplined by any college, university, or professional school for: 1) unacceptable academic
performance (academic probation, suspension, dismissal, ect.) or 2) conduct violations?
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BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Are you currently under charge or have been convicted of felony?
☐ Yes ☐ No
If yes, enter an explanation in this box. Include 1) a brief description of the incident and/or arrest, 2) specific charge
made, 3) related dates, 4) consequences and 5) a reflection on the incident and how the incident has impacted your
life.
Are you currently under charge or have been convicted of a misdemeanor?
☐ Yes ☐ No
If yes, enter an explanation in this box. Include 1) a brief description of the incident and/or arrest, 2) specific charge
made, 3) related dates, 4) consequences and 5) a reflection on the incident and how the incident has impacted your
life.
Dental students interact with patients from many backgrounds. Other than English, indicate any language in which
you feel comfortable conversing with native speakers:
Additional Language 1:
Additional Language 2:
8 | P a ge
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Awards, Honors, Presentations, Publications, and Scholarships
Name:
Dates:
Organization:
Name:
Dates:
Organization:
Name:
Dates:
Organization:
Name:
Dates:
Organization:
Name:
Dates:
Organization:
Dentistry/Shadowing Experience
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
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BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
Supervisor:
Total Hours:
Type of Dentistry:
Dates:
Positions Type:
Brief Description:
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BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Extracurricular/Volunteer/Community Service
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
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BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
Organization:
Total Hours:
Position Title:
Average Weekly Hours:
Dates:
Brief Description:
12 | P a ge
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Employment
Employer:
Total Hours:
Position Title:
Dates:
City, State:
Brief Description:
Employer:
Total Hours:
Position Title:
Dates:
City, State:
Brief Description:
Employer:
Total Hours:
Position Title:
Dates:
City, State:
Brief Description:
Employer:
Total Hours:
Position Title:
Dates:
City, State:
Brief Description:
Employer:
Total Hours:
Position Title:
Dates:
City, State:
Brief Description:
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BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Research Experience
Investigator:
Total Hours:
Project Location:
Dates:
Position Title:
Brief Description:
Investigator:
Total Hours:
Project Location:
Dates:
Position Title:
Brief Description:
Investigator:
Total Hours:
Project Location:
Dates:
Position Title:
Brief Description:
Investigator:
Total Hours:
Project Location:
Dates:
Position Title:
Brief Description:
14 | P a ge
BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM (BMPD)
Disadvantaged Student Section
Do you believe you may qualify as a disadvantaged applicant (social, economic, or educational)?
☐ Yes ☐ No
Reasons may include, but are not limited to:
Please provide a description of the area(s) where you spent the majority of your life from birth to age 18, including
the city, state, and country.
Did you grow up in a single parent household?
☐ Yes ☐ No
I
f yes, please describe in the box below
Number of siblings:
Provide any information about your background that can help clarify your disadvantaged student status.
☐ First generation to attend college
☐ Graduated from high school with low graduating number
☐ Graduated from high school with high percentage of free/reduced lunches
☐ I/family receive public assistance (e.g Families with Dependent Children, food stamps, Medicaid, public housing)
☐ Family lives in area designated as a health profession shortage area or medically underserved
☐ From high school where 50% or less of graduates go to college
☐ From high school where college education is not encouraged
☐ English not primary language
Participated in an academic enrichment progran funded in whole or in part by the Health Careers Opportunity
Program High school dropout who received AHS diploma or GED
Diagnosed with a physical/mental impairment that limits participation in educational opportunities offered by a college
Accepted to the health professions program after academic reassessment at the completion of remedial courses
Come from an economically disadvantaged background
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Marquette BIOMEDICAL SCIENCES PRE-DENTAL POST-BACCALAUREATE PROGRAM application

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Completed 25 December 2019

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