Dedicated to Minnesota Dentists - Eligibility Screening

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Biographical Information

Stage 1 of 4. (Applicant's Information)

First Name

Middle Name

Last Name

Phone

Alternative Phone

Address

City

State

Zip / Postal Code

Stage 2 of 4. (Educational History)

Undergraduate School

Degree

Attending Start Date

Attending End Date

Graduation Date

Dental School Information

Dental School

Degree

Attending Start Date

Attending End Date/Antcipated

Graduation Date/Anticipated

Additional Undergraduate , Graduate, or Dental School Information, if any.

Stage 3 of 4. (Financial Information)

Undergraduate Education Cost and Debt.

Total Education Cost:

Total Education Debt Upon Graduation:

Current Outstanding Debt:

Dental / Graduate School Education Cost and Debt.

Total Education Cost:

Total Education Debt Upon Graduation:

Current Outstanding Debt:

Stage 4 of 4. (Professional Plans)

Intended Practice Location (City/Town, County)

Is this location a Dental Professional Shortage Area?

Plan for New Practice

Please briefly describe the opportunity and your plans. *There is an 800 character limit.

Estimated Start Date

Do you have an existing Minnesota Dental license?

YesNo

If yes, where are you currently practicing? Please enter the practice name and address.

If no, when do you anticipate obtaining a Minnesota Dental license?

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