Dental Assisting Program Registration
Registration fee $95. Non-refundable. By entering your credit card information below, you agree for the company to charge the registration fee.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Your answer
High School Attended *
Your answer
High School Graduation Year *
Your answer
Credit Card Number *
Your answer
Name under Credit Card *
Your answer
Credit Card Type *
Credit Card Expiration Date *
Your answer
Credit Card Security Code *
Your answer
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