Registration Form 2026-2027

Registration Form for 2026-2027 Class

The Puerto Rico MaxiCourse® Program and Clinical Residency in Implant Dentistry
NAME
Degree
License No
AGD
State
AAID
Mailing Address
Email
example@example.com
Phone Numbers: Office Cellular
Office
Please enter a valid phone number.Format: (000) 000-0000.
Cellular
Please enter a valid phone number.Format: (000) 000-0000.
Home
Please enter a valid phone number.Format: (000) 000-0000.
Total cost of tuition: $27,950.00

* Payments in Full have a 7% discount (does not apply to payments with a credit card)

Deposit: $2,000 (non-refundable) Payment: Money Order:
Check Number
Date

MonthDayYear
Date
Name on Card
Card Number
Exp. Date

MonthDayYear
Date
Signature
Date

MonthDayYear
Date
Should be Empty: