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Continuing Dental Education

Course Pre-Registration (Step 1 of 5)


Course Code: 15-DE-003
Course Title: Advanced Functions in Dental Assisting: A DA II Prep Course
Course Date: October 31, 2014


Your First Name:*
Your Middle Name:
Your Last Name:*
Suffix: Jr.    Sr.
Preferred Name:*
Occupation:* Dental Assistant ($425.00)
Dental Hygienist ($425.00)
Dental Lab Technician ($425.00)
Office Staff ($425.00)

Sex: Male    Female
Is this your 1st time registering for a course?
yes no
Do you have a disability or special need?
yes no
Do you need to register additional people?
If so, how many?