P1252428386CLyYi

1
Application for Admission Dental Assistant and
Dental Business Administration Staff Training
Program Nida A. Marouf, D.M.D., LTD 5787 N.
Lincoln Ave, Chicago, IL 60659 [phone]
[phone] (Fax) www.dentalassistant.us
PERSONAL INFORMATION (Please print or type)
Male Female

Full legal name __________________________________
___________________________________ Social
Security _____________________________________
Date of birth _______________________
Place of birth ___________________________________
Local mailing address _________________________
_______________________________________
City ______________________________
State ___________________ ZIP __________________
Email __________________________________
___________ Home telephone
______________________ Work telephone
________________________________
Citizenship
US Citizen State of Legal
Residence_________________________________________
__ US Permanent Resident Alien
Registration Number ______________________________
_ International Applicant Country of
Citizenship__________________________________
Visa type and Number _________________________
_________
Ethnicity (optional)
Black American/Non Hispanic
Asian/Pacific American Indian/Alaska
Native Hispanic White/Non Hispanic
2
Please list every college or university that you
have attended or are attending. Attach additional
page, if necessary. School Name
Location Dates
Attended Degree Earned
______________________ _______________________
________________ ______________
______________________ _______________________
________________ ______________
______________________ _______________________
________________ ______________
Previous Education

Academic honors, awards, prizes
List any academic honors, awards, prizes or
other recognition you have received.
________________________________________________
________________________________________________
__________________________________________________
________________
Volunteer Experience
Indicate the non-profit, community, business, and
professional organizations in which you have been
actively involved. (List by order of personal
significance). Organization
Dates
Role/Position_______________________
_____________ __________________________________
_______________________________ _____________
__________________________________________
Communications
Written communication Fair
Good Excellent Comments
_________________Oral communication
Fair Good Excellent
Comments _________________
Personal Statement
On a separate sheet of paper, explain why you are
interested in pursuing the Dental Assistant and
Dental Business Administration Staff Training
Program. Describe the ways in which you would
make a special contribution to the learning
experience of others in your classes.
3
Please list your three most recent positions.
Employer ______________________________ Type of
Business _____________________________Address
____________________________ City
________________ State __________ ZIP
________Position _______________________________
Dates Employed From ___________ To
___________Employer ____________________________
__ Type of Business _____________________________
Address ____________________________ City
________________ State __________ ZIP
________Position _______________________________
Dates Employed From ___________ To
___________Employer ____________________________
__ Type of Business _____________________________
Address ____________________________ City
________________ State __________ ZIP
________Position _______________________________
Dates Employed From ___________ To ___________
Work Experience

General
Have you ever been, or are you currently under
probation, suspension, or dismissal from any
institution you have attended? Yes
No If yes, please give details. Have
you ever been charged with or arrested for a
crime other than a minor traffic violation?
Yes No ? If yes, please
explain in detail the nature of the crime, the
circumstances surrounding the charges or arrest
and the disposition.
References
Provide the names and phone numbers of three
references people _______________________________
__________________________________________________
_ ________________________________________________
__________________________________________________
__________________________________________________
________________
I hereby certify that the information I have
provided in this application and in any
supporting documents is complete and correct to
the best of my knowledge. I further authorize
Nida A. Marouf, D.M.D., LTD to contact my
references people and make appropriate and
complete inquiries when necessary to certify the
accuracy of my records. Dated
______________________ Signature
__________________________________________