UIC IDDP Applicant
Payment page

__________________________________________________________________________________

Last / Family Name / Surname                               First / Given / Personal                            Middle

Address:                _______________________________________________________________

City, State:   ____________________________________   Nation:   ________________________

Zip:  _______________________

Application Term:     _____ Summer              Year: 20_____

International Dentist Degree Program

Date of Birth:    _________________     Social Security Number:   _________________________

Thank you for applying for admission to the University of Illinois at Chicago (UIC). To complete your file, please have your official test scores and transcripts sent to the College of Dentistry. If you are paying your $150 nonrefundable application fee by check or money order, please print & complete this document, include your check and send both to:

UIC College of Dentistry
International Dentist Degree Program
Admissions Office
801 S. Paulina, MC621, Room 104
Chicago, Illinois 60612-7211