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HJ????G??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ??^bjbjcTcT .&>>^???????? ? ????????????? ?,?e0.'''''f| ??/?/?/?/?/?/?/$?1?54? 0?+bf++ 0??'';0???+ ?'?'?/?+?/???)?L+'?????y!???5 ?*&?/500e0+J?4?@?4LL+L+ ?4?X/x??>|??d??? 0 0@???e0++++?????????????????????????????????????????????????????????????????????4?????????? ?: UNIVERSITY OF TOLEDO COLLEGE OF MEDICINE POST GRADUATE MEDICAL EDUCATION PROGRAMDIVISION OF DENTISTRYAPLICATION FOR TRAINING STARTING: ____________________________________, 20____Type of Training Desired: ________________________________________________________________Name: _______________________________________________________________________________Present Address: ________________________________________________________________________Home Address: ________________________________________________________________________Phone Number ___________________________________________Birth Date: _______________ Sex: _____ Visa Number: _________________________ Birthplace: __________________________ Citizen of: __________________________________ Marital Status: ____________________ Dependents: _______ Social Security #: _________________Spouse?s Name: __________________________________ Occupation: _________________________Notify in Emergency: ________________________________________________________________Military Status: _______________________________________________________________________Education History:Undergraduate: ___________________________ Dates: ________________ Degree: _______ Dental School: ___________________________ Dates: ________________ Degree: _______ Other Graduate Training: ____________________ Dates: ________________ Degree: _______ Post Graduate Training: __________________________________________ Dates: ______________ Licensures: _________________________________________ Number: _____________________ State or Province _________________________________________ Number: _____________________ State or ProvinceState Board Examination: ____________________ Results: ____________________________________ DateEnrolled in National Dental Intern Resident Matching Program? Yes: ___________ No: _________Membership in scientific organizations: _________________________________________________________________________________________________________________________________________________________________________________________________________________________Hospital Experiences (other than listed above): _______________________________________________________________________________________________________________________________________________________________________________________________________________________Research Experience: ______________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________ Outline Future Objectives (Academic Dentistry, Private Practice, Specialty, etc.): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________References (should be individual letters requested by applicant one must be from the Dean)_______________________________ ___________________________ _____________________Name Address Title_______________________________ ___________________________ ____________________________________________________ ___________________________ _____________________ Present State of Health (supplement where necessary): _________________________________________Enclosures: (1.) Photo (2 copies) (2.) Resume (3) Original Dental School TranscriptApplicant Signature ________________________________ Return Application to: William J. Davis, D.D.S., M.S. Program Director General Practice Residency Program University of Toledo 3000 Arlington Ave. Mail Stop 1092 Toledo, Ohio 43614)*Rhi? k ? ?y}?,?????<??? O_gm????JZ]^???????????????̹?????????????????????????h?O:h1j5CJaJh?O:CJaJh?U?h?V?CJaJh?U?h?a;?CJaJh?aCJaJh?U?h?aCJaJh?U?h?a;?OJQJh?U?h?a5?CJaJ h?O:CJh?U?h?aCJhwT?h?aOJQJ^J*Rhi??  o p ? ? 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