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Madison Nichols
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1 The University of New Mexico Health Sciences Center Division of Dental Hygiene MSC UNIVERSITY OF NEW MEXICO Albuquerque, New Mexico Phone (505) Fax (505) Attach passport photo here Bachelor of Science Degree in Dental Hygiene APPLICATION FORM (Please Print Or Type) Date: Please circle how many times have you applied to the program? Name: Last First Middle Initial Maiden Name Birth date: / / Lobo Banner ID Mo Day Yr Present Mailing Address: street city state zip code Home Ph: Work Ph: Cell Ph: Address to which you want your correspondence to be mailed after September 1 st : street city state zip code Permanent Phone: If a change in your legal address is planned, please explain in the space provided: (Check One) I am currently enrolled in UNM I have applied or am currently applying for admission to the University of New Mexico Date attended Dental Hygiene Advisement Session If you are not currently attending UNM, what school, if any, are you attending? Name of School Name of Current Employer: Location: City and State Position: Have you had dental employment experience in the past, or are you currently employed in this area?

0 1 2 3 4 Name: Last First Middle Initial Maiden Name Birth date: / / Lobo Banner ID Mo Day Yr Present Mailing Address: street city state zip code Home Ph: Work Ph: Cell Ph: Address to which you want

2 Dental employment, experience, or observation: (list employer, firm name, dates of employment, and number of hours worked or observed per week). Briefly answer the following questions: Employment: 1. Briefly list any jobs you have held up to this point. 2. How do you feel any of these positions may have helped you prepare for a possible career in dental hygiene? DENTAL HYGIENE: 1. What qualities do you feel are important for a dental hygienist to possess? 2. How did you become interested in dental hygiene? Education: 1. How many colleges or universities other than UNM have you attended? (list others) 2. If you have changed your major, what was your previous major and why did you change? 3. How many semesters of college work have you completed? Semesters

How do you feel any of these positions may have helped you prepare for a possible career in dental hygiene? DENTAL HYGIENE: 1.

3 4. If you have earned a degree, please specify the field AS PART OF THE APPLICATION YOU MUST ALSO COMPLETE THIS FORM. See descriptive information regarding each course in prior section. Material on these pages will be especially helpful for students wishing to transfer from other colleges. If you are currently taking a course, indicate this by writing in progress in the appropriate space. Also, it is necessary for you to provide the name of the school as well as the semester and year this is occurring. Courses English 101 COMPLETED? YES/NO In Progress? TAKEN MORE THAN ONCE? YES/NO Highest Grade Received SEMESTER and YR COMPLETED IF COMPLETE, SCHOOL IN WHICH TAKEN IF NOT YET COMPLETE, SCHOOL, SEMESTER, & YR YOU WILL English 102 *C & J 221 or C & J 130 * C & J 221 preferred, but C & J 130 will be accepted. Math 145 Nutrition 244 Humanities 6 hrs Bio 123 and Lab Bio 237 (A&P I) Bio 247 Lab Bio 238 A&P II Bio 248 Lab Chemistry 111 Chemistry 212 Microbiology 239 Psychology 105 Sociology 101 Second language 3 hrs Fine Arts

If you are currently taking a course, indicate this by writing in progress in the appropriate space.

4 3 hrs BRIEFLY IN ( ) WORDS DISCUSS YOUR REASONS FOR WANTING TO BECOME A DENTAL HYGIENIST. (Type or Print)

5 Application Check List (Call to perform a FILE CHECK after materials are sent to insure all materials are received before deadline of September 1 st. It is the student s responsibility to insure all materials are received in a timely fashion. You will not be notified if your application is incomplete. Applicants with incomplete applications will not be considered.) 1. Application to the University of New Mexico completed and turned in to Admissions Office. 2. Dental Hygiene application completely/correctly filled out. 3. Check or money order for $100, for application fee. If you are paying by credit card, see Administrative Assistant for special instructions. 4. Any and all official transcripts. Must be in sealed official envelope. 5. Any and all letters confirming employment or volunteer hours in the dental field. 6. Any other documents requested specifically by the division. 7. Credit Evaluation statement (Progress Report) can be accessed through LOBOWEB. Put all materials in manila envelope and mail to: Admissions Coordinator of Dental Hygiene MSC University of New Mexico Albuquerque, NM Deadline for turning in application and additional materials is September 1 st. No exceptions.

Applicants with incomplete applications will not be considered.) 1. Application to the University of New Mexico completed and turned in to Admissions Office. 2.

Dental Hygiene Application

Dental Hygiene Application Filing Period: February 1 st - June 1 st Last Name First Name Middle of Birth Social Security Number PCC ID (if applicable) Mailing Address City State Zip Code Email Address