Supplemental Application Form - Dalhousie University (Page 2 of 2) in pdf

Have you applied for admission to the Dalhousie Dental Hygiene program in previous years?

 Yes

 No

If yes, when? Year __________________ Year ___________________

Do you consent to our review of last year’s application?

 Yes

 No

Have you applied to Dental Hygiene program(s) other than Dalhousie this year?  Yes

 No

If yes, which program(s)? ___________________________________________________________________________________

Have you, in previous years, failed to gain admission to other Dental Hygiene programs?  Yes

 No

Have you attended any other Dental Hygiene Programs?  Yes

 No

If yes: __________________________________________________________________________________________________

Where? _________________________________________________ When? __________________________________________

Are you eligible to continue there?

 Yes

 No

Because of the nature of the study and practice of dental hygiene which places you in a position of special trust, the Faculty of Dentistry requires

you to answer the following questions:

Have you ever been convicted of a criminal offense for which you have not received a pardon?

 No

 Yes If yes, explain: ______________________________________________________________________________

Is there anything in your background which would impact in an adverse way your legal or ethical suitability for the practice of dental hygiene?

 No

 Yes If yes, explain: _______________________________________________________________________________

Any applicant who responds “yes” to the above questions will still be considered for the program. By submitting this application, you are agreeing

that the Faculty of Dentistry Admissions Committee may contact third parties to obtain additional information.

REFERENCES: Please list 3 individuals (not relatives) who would provide a reference on request. It is recommended that at least one of

these be from an individual who has taught you; one from an employer (if applicable) and one other.

Name

Address

Telephone

Occupation

The Admissions Committee will contact your references directly if a reference is required.

Work experience held during academic session and summers (length of time, hours per week) or full-time (if full-time please explain reasons for

leaving university).

______________________________________________________________________________________________________

In the event that you are accepted to Dalhousie University’s School of Dental Hygiene, our clinic staff needs to know whether you are right or left-

handed to assist them in setting up the clinic cubicles for your use. Please indicate:

I am:  Right-Handed

 Left-Handed

Please use additional pages if you have other information you wish to be considered by the Admissions Committee.

Supplemental Application Form - Dalhousie University Page 2