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
Format: (000) 000-0000.
Gender
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any dental assisting experience?
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.
Signature
Should be Empty:

Supreme Dental Assistant Program Application