Course Registration Form

Application for Orthodontic Expanded Duties Functions Module
Applicant Information

By completing this form you hereby agree that you have a minimum of six months experience as a dental assistant or have graduated from an ADA Accredited Dental Assisting Program and have been trained on a typodont in Procedures in the Florida State Board of Dentistry, rule 64B5-16.005 and 16.008. The fee for the certification module is $150.00, and includes both the orthodontic expanded duties and the orthodontic clinical crown tooth polishing modules.
Name*

First NameLast Name
Last 4 digits of Social Security Number *
Email Address*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer Information

Employer must sign off prior to testing
Name of Employer*
Employer Phone Number*
Employer Email*
example@example.com
Employer Address*

Street Address

Street Address Line 2

CityState

Zip Code
Module and Location

Please open the PDF in your email for important information after submitting the form.
Have you taken Orthodontic Expanded Functions module previously?*

YesNo
If so, when? Date
Have you taken Orthodontic Tooth Polishing module previously?*

YesNo
If so, when? Date
Module to be taken*

Orthodontic Expanded FunctionsOrthodontic Tooth Polishing
Test Site*

January - Ft. LauderdaleFebruary - TampaFebruary - Fort Walton BeachMarch - Palm Beach GardensApril - OrlandoMay - BradentonJune - Sebring (1 spot left)September - MiamiSeptember - OcalaOctober - ClearwaterNovember - NaplesDecember - Jacksonville (Currently Unavailable)
Payment

Expanded Duties ModuleThe fee includes both the orthodontic expanded duties and the orthodontic clinical crown tooth polishing modules. If you are currently certified in one of these areas, your attendance and participation in that area is not required. However, the fee is not reduced if only one portion is taken.

$150.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human
Signature

Clear
Should be Empty:

Application for Orthodontic Expanded Duties Functions Module

Applicant Information

Employer Information

Module and Location

Payment