Forensic Odontology Fellowship 2011.2012

The University of Texas Health Science Center at San Antonio

Center for Education and Research in Forensics

201

1-12 Forensic Odontology Fellowship Application

This application should be typed or completed in black ink.

Date of Application:________________ Projected entry date:

March 2011

Length of Fellowship Applied for: 2

Name:_______________________________________________________________

(

2 Months (330 Contact hours)Last Name) (First Name) (Middle Name)

Social Security Number (

Mal

if applicable):_____________________________________e Female Date of Birth:_________________

(Month/Day/Year)

City and Country of Birth:_____________________________________________

Country of Citizenship:________________________________________________

Country of Legal Permanent Residence (

Office Address: _____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

Home Address: _____________________________________________________

_____________________________________________________

_____________________________________________________

Telephone: Work (____)____________ Home (____)______________

Fax number: Work (____)_____________ Home (____)________________

e-mail address: ________________________________________

webpage address: ______________________________________

EDUCATION: List Colleges, universities and professional schools attended

__________________________ _________ _________________

School Degree Graduation Date

__________________________ _________ _________________

School Degree Graduation Date

__________________________ _________ _________________

School Degree Graduation Date

Are you a citizen of the United States of America? Y N

If no, will you obtain health insurance while in the United States? Y N

if different):__________________________

COMPLETE THE FOLLOWING INFORMATION IF YOU ARE A CITIZEN OF ANOTHER COUNTRY, BUT PRESENTLY RESIDING IN THE U.S.A

Please list acquaintances in the Forensic field that you might have that we may contact for a reference.

____________________ (____)___________________

. Type of Visa: __________________________________________

Name Telephone

email address ____________________ (____)_____________________________________ Name Telephone email address

Describe your level of experience with computers:

None Beginner Intermediate Experienced

Have you published on any phase of dentistry or other science? If yes, attach list.

What word processing program

use?

(s) do you________________________ Are these squares identical? __________

Do you have experience using Adobe Photoshop? Y N

Do you take intraoral photographs in your dental practice? Y N

What type of camera do you use?________________________________________