Online Doctor Appointment Form

Supreme Dental Assistant Program Application

Fill out the form accurately indicating your potentials and suitability to the program.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Phone Number*
Gender
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any dental assisting experience?*

YesNo
If so, please explain what dental assisting experience you have?
Employment and Educational Background
High School Name*
City and State*
Graduation Date or Equivalency Date*
Month and Year
Certificate of Completion/GED*

Cancelof
College University
Graduation Date
Month and Year
Credential Awarded
Current/Most Recent Employer *
Cancellation Policy

You may cancel the enrollment agreement or contract by WRITTEN NOTICE, without any penalty or obligation, and receive a FULL REFUND BEFORE THE FIRST DAY OF CLASS. The enrollment agreement is not binding until signed by the school director or designated school official. An enrollment fee of $150.00 is applied towards your tuition; however, if you choose not to attend the program this will become a NON-REFUNDABLE fee on the first day of class.

Please note that refunds will not be provided after the first week of class.
By submitting this application , you agree that you have answered all questions truthfully and to the best of your knowledge.*

I agreeI disagree
Signature *

Powered by Jotform SignClear
Should be Empty:

Supreme Dental Assistant Program Application