Application
Form—Advanced Endodontic Technique—July, 2010
I.
Personal Information
First Name Last Degree(s)
Home Address:
City State Zip
Code
Phone(s):
Home : Office
Cell
Fax E-mail
II. Practice History and Dental Education Information
Are currently licensed to practice
dentistry in the State of
If “No”, in what state/country are
you currently licensed:
Schools Attended:
6.
BS/BDS Year
Graduated
7.
DMD/DDS Year
Graduated
8.
General Practice Residency Year
Graduated
9.
Specialty Year
Graduated
a.
Are you Board Certified in your Specialty:? ¨ Yes ¨ No
III. Experience
in Endodontics
11.
How would you categorize your dental school training in Endodontics:______ o Limited
o Extensive
12.
In an average year, how many continuing education education
courses do you attend?
o Only 1
o More than 1
but less than 5 oMore than 5 but less than 10 o 10 or more
13.
What characteristics most influenced your decision to enroll in this course.?
o The opportunity to interact on a day-to-day
basis with postgraduates and faculty
o The
comprehensiveness of the array of topics covered
o The
opportunity to work independently in lab on personal projects
o The
opportunity to learn how to best use equipment (operating microscrope,
Apex locators, rotary instrumentation) in your practice. o Exposure to a
different education setting/facility than the school/city in which you were
trained and/or currently practice.
14. If you’ve taken any Endodontic hands-on
courses since completing dental school, list those that you feel have been most
helpful to you in practice.
a..
Course Sponsor________________________________________________________________________________
b..
Course
Sponsor________________________________________________________________________________
.c..
Course
Sponsor________________________________________________________________________________
.d..
Course
Sponsor________________________________________________________________________________
.e..
Course
Sponsor________________________________________________________________________________
15.
What other types of dental education courses have you taken over the
past 5 years that you believe are similar to the type of program we are
offering?
a..
Course Sponsor________________________________________________________________________________
b..
Course
Sponsor________________________________________________________________________________
.c..
Course
Sponsor________________________________________________________________________________
.d..
Course
Sponsor________________________________________________________________________________
.e..
Course
Sponsor________________________________________________________________________________
17. Describe briefly what you expect to learn/gain from your
participation in this course and what impact, if any, you expect this to have
on your practice?
IV. Advanced Endodontic Technique
Applicant
Informed Consent:
Placement in this course is limited to two (2) dentists per
year. I understand that, if I am
accepted into this course, I am agreeing to participate in a program of
postgraduate education with departmental residents that will award equivalent
continuing education hours of credit (lecture and participation) under the
approved provider specifications of the American Dental Association Continuing
Education Recognition Program (ADA-CERP) and the Academy of General Dentistry
Program Approval for Continuing Education (AGD-PACE). AGD credit is applicable to both Fellowship
and Master Track requirements.
I also understand that my affiliation to the University of Illinois College of Dentistry and the Department of
Endodontics is limited to this single course and does not imply student
status. Registration is managed through
the Department of Endodontics and is contingent upon the approval of the
Department and its faculty. An
application does not guarantee acceptance.
The course fee is $5,000, including a $500 application/deposit, payable
with submission of this application form, and the cost of required
equipment. Applications not accepted
will be returned with a full refund of the $500 application/deposit fee.
Method of Payment
Check Credit
Authorization*
¨ #________ ¨ Discover ¨ Mastercard ¨ VISA Exp.___/_____
Amt. $_______.___ |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Amt. $________.___
Payment authorization (Original cardholder signature required for
credit/debit card transactions.)
*Cardholder Signature Date
Submitted
Applicant Signature (if other than above) Date Submitted
Submission Instructions: Return this form, signed, with deposit to:
Phone: 312-996-7514, Fax: 312-996-3375, E-Mail: nancylee@uic.edu