Deans Certification Form (Page 2 of 2) in pdf

Boston University Henry M. Goldman School of Dental Medicine

Dean’s Certification

To the accepted DMD applicant: Please complete the top section of this form and then deliver the form to the current dean or

administrative officer in charge of students at your degree-granting undergraduate institution. The dean should send this form

directly to the Boston University Henry M. Goldman School of Dental Medicine Office of Admissions in an envelope that has been

sealed and signed across the seal. The form should be submitted to Boston University Henry M. Goldman School of Dental

Medicine by June 1

, and preferably within 30 days of acceptance.

Accepted DMD applicant: Complete this section of this form.

Name of applicant

LAST

FIRST

MIDDLE

AADSAS #

Undergraduate ID#

Undergraduate Institution

□

Dates of attendance

Degree

awarded

expected in

Major

This certification will become part of your admissions file. It will not be disclosed to any unauthorized individual without your

consent. If you matriculate at Boston University, you will be accorded access to its contents unless you voluntarily waive your right

of access. Please check one of the boxes and sign the statement below.

□

I have read the information above and I hereby

waive

do not waive

my right of access to this document should I

matriculate at Boston University.

Signature_________________________________________________

__ Date ___________________

___

______

To the accepted DMD applicant: After signing above, submit the form to your undergraduate dean for completion.

Undergraduate Dean: Please complete and mail the form to Boston University School of Dental Medicine

Memorandum to Deans: Under the 1974 Family Educational Rights and Privacy Act, the applicant named above will have

access to this certification unless he or she has waived that right.

Personal knowledge of the applicant is not necessary. If the space provided is insufficient, please continue your answers on the

reverse side of this form or attach your own letterhead.

Questions 1 and 2 must be answered.

□

Do you have access to the applicant’s college file?

Yes

If you do not have access to the applicant’s college file, please return this form to the applicant.

Has the applicant ever been subject to disciplinary action or proceedings for academic or personal misconduct, or subject to

any action for academic insufficiency, at any college or university?

The issue of a disciplinary record (or absence of one) must be directly and explicitly addressed in writing.

□

Yes

If yes, please explain.

Please provide any other pertinent information in the files of the college, including, if possible, class standing. If you are

acquainted with the applicant and wish to add your evaluation of his or her ability, character or motivation for the study of

dental medicine, please do so.

Class Standing: ____________

Signature

Date

Name (printed)

Title or position

Institution

Telephone

Thank you for your assistance.

Please send the completed certification (in an envelope that has been sealed and signed across the seal) to:

Boston University Henry M. Goldman School of Dental Medicine, Office of Admissions

100 East Newton Street, G-305, Boston, MA 02118 USA

Deans Certification Form Page 2

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