February 2025 Registration Form
Fill out the form carefully for registration
Name (as it appears on your license)
First Name
Middle Name
Last Name
E-mail
example@example.com
E-mail confirmation
example@example.com
License number (n/a if you do not have a license number); phone number
License types
RDH
RDHAP
RDA/RDAEF
DDS
Student
Membership Status (membership status will be verified)
Potential Member (Non-members of CDHA/DDS/RDA/RDAEF)
CDHA members
Student members
Student non-members
My Products
*
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next
( X )
Potential Member
Non-members/DDS/RDA/RDAEF
$
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
CDHA Member
membership will be verified
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Student Member
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
Student Non-member
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: