OSF Saint Francis Medical Center

Peoria, Illinois

Dental Residency Application

Application Requirements:

The applicant must have completed or be in the process of completing a dental degree program at a school accredited by the American Dental Association.
Applicant must be eligible for Illinois permanent residency status.
Applicant must complete and submit the attached application and requested enclosures.

Note: If accepted into the program, applicant must have reliable transportation due to the need to travel between multiple teaching locations

For additional information on the application process, please call Dr. Paul Amodeo, at 309-624-9741.

* indicates a required field.

First Name: *

Last Name: *

Middle Initial: *

Home Phone: *

Cell Phone: *

A member of the Admissions and Selection Committee may attempt to contact you by telephone sometime during the application process. The purpose of this call will be to conduct an informal interview and/or to advise you of the status of your application. Please be sure the phone numbers above are accurate.

Your preferred contact number is: *

Home
Cell

Email: *

Why are you interested in attending the OSF Saint Francis Medical Center General Practice Residency Program? *

Current Address

Address: *

City: *

State: *

Zip: *

Permanent Mailing Address

Please provide if different than your current address.

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip:

Please select one, I am a: *

U.S. citizen
Alien legally authorized to work in the U.S.

Education and Training

Dental School Name (1):

Dental School (1) Location:

Dental School (1) From:

Dental School (1) To:

Dental School (1) Degree:

Dental School (2):

Dental School (2) Location:

Dental School (2) From:

Dental School (2) To:

Dental School (2) Degree:

Undergraduate College(s)

Undergraduate College (1):

Undergraduate College (1) Location:

Undergraduate College (1) From:

Undergraduate College (1) To:

Undergraduate College (1) Degree:

Undergraduate College (2):

Undergraduate College (2) Location:

Undergraduate College (2) From:

Undergraduate College (2) To:

Undergraduate College (2) Degree:

Undergraduate College (3):

Undergraduate College (3) Location:

Undergraduate College (3) From:

Undergraduate College (3) To:

Undergraduate College (3) Degree:

Confidential Information

Honors Received:

Extracurricular Activities:

Research Experience:

Publications:

Resume of Private Practice (if applicable):

Resume of Military Service (if applicable):

Employment since Graduation (if applicable):

Licensed to Practice Dentistry

License (1) State:

License (1) Number:

License (1) Date:

License (2):

License (2) Number:

License (2) Date:

License (3) State:

License (3) Number:

License (3) Date:

Have you ever applied for residency at OSF Saint Francis Medical Center before?

If yes, when?

Do you have any disability that would prevent your engaging in the active practice of Dentistry?

Certification

I understand that withholding information requested on this application or giving false information will cause me to be ineligible for admission or subject to dismissal. With this in mind, I certify that the forgoing statements are correct and complete. I further certify that if accepted for admission, I shall comply with the rules of OSF Saint Francis Dental General Practice Residency Program

Attachments

Dental School Transcript:
Combined file sizes cannot exceed 15MB

Letter of Recommendation from the Dean:
Combined file sizes cannot exceed 15MB

Letter of Recommendation 2:
Combined file sizes cannot exceed 15MB

Letter of Recommendation 3:
Combined file sizes cannot exceed 15MB

National Board Scores Part I:
Combined file sizes cannot exceed 15MB

National Board Scores Part II:
Combined file sizes cannot exceed 15MB

Application Fee

Please send a check or money order for $50.00 [not refundable] payable to OSF Saint Francis Medical Center to: Dr. Mary Joyce Gomez Dental General Practice Residency OSF Saint Francis Medical Center 530 NE Glen Oak Avenue Peoria, Illinois 61637