School of Dental Medicine Student Request for Information Form

Thank you for your interest in the School of Dental Medicine at the University of Pittsburgh. By completing the following form you will receive information about upcoming events, application deadlines, and specific program information tailored to your interests.

Items marked with an asterisk (*) are required in order to best meet your needs and interests.

Are you a U.S./Domestic or International Student?

Are you currently a student at the University of Pittsburgh?

YesNo

Expected Year of Graduation

Affiliation Role

Pitt Indicator

Email Address

Email

Verify Email

Email Validation Error

Contact Details

First Name

Preferred First Name

Middle Name

Last Name

Birthdate

Sex at birth

Gender

Other Gender

Preferred Phone Number

Mailing Country

Mailing Street

Mailing City

Mailing State

Mailing Postal Code

I am a U.S. Veteran

Given Name

Preferred Name

Middle Name

Family Name

Birthdate

Sex at Birth

Gender

Other Gender

Preferred Phone Number

Country of Residence

Country of Citizenship

I have a visa sponsor

Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino/a

Native Hawaiian/Other Pacific Islander

White

Have any of your family members attended the University of Pittsburgh’s School of Dental Medicine?

YesNo

Mother

Father

Sibling

Grandparent

Aunt

Uncle

Cousin

Enrollment Information

Degree of Interest

Program of Interest

Intended Concentration

Advanced Standing?

Term of Interest

Student Type

Application Center

Current Educational Status

I am currently in

University or college currently attending

Account ID

My school is not listed

Affiliation Role

Highest Degree Earned

Expected Year of Graduation

GRAD Data

Lead ID

GRAD UTM

Lead Source

Lead Subsource