McGill University

Faculty of Dentistry

Forensic Dentistry Course Application Form 2017-18

NAME:

________________________________________________________________________________Surname First Middle name

MAILING ADDRESS:

Number and Street ____________________________________________________ Apt. __________

__________________________________________________________________________________ City Province/State Country Postal Code

Telephone: Day_____________________ Evening ___________________ Cell: __________________

Email: _________________________________________ Fax: _____________________________

PERMANENT ADDRESS: (if same as mailing address, check here)

__________________________________________________________________________________ City Province/State Country Postal Code

Telephone Number: Day __________________________ Evening ________________________

COUNTRY OF CITIZENSHIP _________________________________________________________

DENTAL SCHOOL _________________________________________________________________

Degree ____________________________________ Year of Graduation _________

Post-graduate Experience ____________________________________________________________

_________________________________________________________________________________

Number and Street ____________________________________________________ Apt. __________

LICENSURE

Do you hold a license to practice Dentistry? YES NO

Province/State ____________________ Country _________________

GENERAL

Date of birth: __________ __________ ________ Year Month Day

Male Female

Place of Birth: _________________________________________________________

Language normally spoken: English French Other_______________

I wish to register for:

September 21 7

22 7

18 28 8 41

1 8 44

7 1 8 41

T E FOLLO IN S OULD E RETURNED ELECTRONICALLY

A. Forensic Dentistry Course Application Form B. A copy of your university dental degree(s) C. A copy of your dental license D. An abbreviated curriculum vitae E. Autobiographical letter of application F. Two confidential reference reportsG. Personal information form “Security Clearance Form 2016” which will be

made available and sent to you later (must only be completed within 6 months of the end date for Module 5)

RETURN ALL FORMS TO:

chantal.desjardins2@mcgill.caChantal Desjardins Program Administrator

OR conted.dentistry@mcgill.ca

m ts te re rs

McGill University

Faculty of Dentistry

7 8

SI NED: DATE:

The application deadline for all modules is June 1, 2016. Acceptance in the program will be announced by no later than June 15, 2016. The faculty reserves the right to accept applications (or not) after the application deadline.

Applications will be evaluated after the non refundable application fee ($150) has been paid online at this lin http www.cvent.com d dv h32 4

The 1st semester fee of $6000.00 (Modules 1 and 2) is due by July 1, 2017.The 2nd semester fee of $4100.00 (Module 3) is due by February 1, 201 .The 3rd semester fee of $ 500 (Modules 4 and 5) is due by April 1, 201 .

REFUND POLICYFor any cancellation made between the payment due dates and the cancellation deadlines (see below), 90% of the registration fee will be reimbursed. Any refund given will be based on the semester fee.

The deadline for cancelling your participation for semester 1 (modules 1 & 2) is August 1,201 , after which date no refund will be given.The deadline for cancelling participation for semester 2 (module 3) is February 15, 201 , afterwhich date no refund will be given.The deadline for cancelling for semester 3 (modules 4 and 5) is April 11, 201 , after which dateno refund will be given.

ADMINISTRATIVE POLICY

Please note that there is a minimum of 10 hours per wee of course wor for modules 1 to 3.iven the significant amount of time re uired to complete the wee ly readings and re uired

e ercises, participants must ensure that they have freed sufficient time in their schedule

McGill University

Faculty of Dentistry

Forensic Dentistry Course

Autobiographical letter of application

LEGAL NAME OF APPLICANT

The autobiographical letter must be written by the applicant. The applicant must comply with the following instructions to ensure consideration of the autobiographical letter. It can be up to three pages in length but no longer. The text must be double spaced in "letter" format with one-inch margins in normal lowercase, Times New Roman font, 10 pitch and included in your attachments with your application.

Letters that fail to meet the above criteria will be discarded. The autobiographical application should contain information regarding the applicant’s reason(s) for taking the forensic dentistry course. Former forensic education, knowledge, association or experience should be mentioned.