RP6193 - Dental Practice Act Enrollment Form

RP6193 - Dental Practice Act Enrollment Form
Important Notice: Please ensure that all information entered is accurate and complete. Your certificate will be generated based on the details you provide, and changes after submission may incur a correction fee.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Please Read Before You Proceed

This is an 2-hour program consisting of online learning and on-site written exam.

After you submit this form, you will be redirected to the online course access page. To begin, you will need to create an account on our website.

You will finish the online session and come in at Sunday at 10AM for your Onsite Written Test.

My Products*

Dental Practice ActNon-Refundable

$50.00

Total

$0.00

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer

Afterpay

After clicking Submit, you will be automatically redirected to the iEducations login page. Use your account credentials to access your Online Course.
Should be Empty: