INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
- PERSONAL DATA
Full Legal Name
Last Name First Middle
Home/Permanent Address
Number Street (Ave., Rd., etc.)
City State Zip Code
Home Telephone Cell/Mobile Telephone
(Area Code) Number Area Code) Number
Home E-mail address: ______
Birthdate:______
- EDUCATIONAL DATA:
If you attended Indiana University previously, and you know your IU Student ID #,please enter it below, including all zeros:
IU Student ID # ______
List below all college education; include current or planned enrollment.
Entered Left Full or Diploma Year Received
Name and location of Institution Month Year Month Year Part-time or Degree or expected
- BACKGROUND QUESTIONS:
BS Degree Completion Program Application: updated May, 2018page 1
INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
Have you ever been arrested or convicted of a crime that has not been expunged by a court?
Yes No
BS Degree Completion Program Application: updated May, 2018page 1
INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
Do you have any currently pending criminal charges against you?
Yes No
BS Degree Completion Program Application: updated May, 2018page 1
INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
Have you ever been refused admission or subject to any disciplinary action (e.g. threated or actual dismissal, expulsion, or probation) at any previous school?
Yes No
BS Degree Completion Program Application: updated May, 2018page 1
INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
Have you engaged in any behavior that resulted in serious injury to any person(s) or personal property?
Yes No
BS Degree Completion Program Application: updated May, 2018page 1
INDIANAUNIVERSITYSCHOOL OF DENTISTRY
B.S. Public Health Dental Hygiene – Degree Completion Program
APPLICATION FOR ADMISSION
If you answered “yes” to any of these questions, please explain in detail. Note that answering “Yes” to any of these questions will not automatically disqualify you from admission, but failure to disclose could result in denial of admission or subsequent disciplinary action, including dismissal.
- SIGN AND DATE THE FOLLOWING STATEMENT.
I hereby give permission to the IUSD Dental Hygiene Program to inspect my application and academic records.
Date ______Applicant’s signature: ______
- CAREER PLAN: On a separate page, please type and attach a 1 –2 page summary of your 5-year professional goals. Your statement should include your reasons for seeking a baccalaureate degree at this time and how you foresee using the new degree to enhance your career.
- PROFESSIONAL RESUME (attach file to application)
PLEASE BE SURE TO SUBMIT THE FOLLOWING WITH YOUR APPLICATION
- College transcripts from all colleges attended other than Indiana University (Official copies will need to be submitted to IUPUI once you are admitted to the Dental Hygiene BS Degree completion program.
- Copy of current Dental Hygiene License
- Career Plan/Goals statement (attachment)
- Professional resume that includes a listing of your professional work experience and other professional activities
- Current Photo-attach print to paper application or digital JPEG photo file (head and neck view similar to passport-size photo)
All application materials should be received no later than 6 – 8 weeks prior to the semester in which the student wishes to be admitted.
Send completed application to:
Lisa L. Maxwell, BSDH Coordinator
Indiana University School of Dentistry
Dental Hygiene Program
1121 West Michigan Street
Indianapolis, IN 46202
Email:
Phone: 317-274-7801 (Dental Hygiene Program Office)
FAX: 317-274-1363
BS Degree Completion Program Application: updated May, 2018page 1