International Dental Student Exchange Program Application

Applicant Infomration

First Name

Middle Inital

Last Name

Birthdate

Please select or type in your date of birth (MM/DD/YY)

Home Address

Please provide full mailing address

Email Address

Phone Number

Year in Dental School

Expected Graduation Date

University Information

Name of University

Name of Dental School Dean

Email of Dental School Dean

Name of Faculty in Charge

Email of Faculty in Charge

Telephone Number of Faculty in Charge

School Telephone Number

Required Format for Telephone Number

+ sign followed by the country code, area code, and local number

School Fax Number

Required Format for Telephone Number

+ sign followed by the country code, area code, and local number

Emergency Contact Person Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Email

Emergency Contact Phone

Required Format for Telephone Number

+ sign followed by the country code, area code, and local number

Name of contact person In United States (If applicable)

Emergency Contact Relationship in United States

Emergency Contact Email in United States

Phone Number of contact person In United States (If applicable)

Required Format for Telephone Number

+ sign followed by the country code, area code, and local number

Arrival/Departure Date

Arrival Date

Departure Date

Additional Information

Areas of special interest during Observation

Please use this space to add additional information (if any) that you would like to share pertaining your application

Application Upload Requirements

Upload the following items:

Photo of Applicant
In Good Standing Form

Drop your files here

I have uploaded my good standing form signed by the School Dean or Designated Official.

Download a copy of the In Good Standings Form.

Please note if you do not upload a signed form your application will be returned and may delay your approval.

I have uploaded a photo of myself.

Send me a copy of my responses

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