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 (optional):   _________________________


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