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Excel Learning Institute Instructional Programs Application
Please complete the online application below for your program of choice. Final processing will occur for completed forms only.
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First Name :
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Last Name:
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Middle Initial:
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Preferred Name:
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Gender:
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Male
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Other:
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Race/Nationality:
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Are you a US Citizen:
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Date of Birth
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Email Address:
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Current Address: (City, State, Zip Code)
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Mailing Address: (City, State, Zip Code)
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Cell Phone Number:
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House Number:
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Emergency Contact: (Name, Number, Relationship)
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Name of High School/GED Program:
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Address of High School/GED Program:
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Date of Graduation:
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Please select the program you are applying for:
Excel Dental Assisting Basic Package
Excel Dental Assisting Platinum Package
Excel Radiology RHS Review
Excel Dental Billing and Insurance Review
Payment Options: All Money Orders should be mailed to Advanced Dentistry of Collegeville, 399 Arcola Road #100, Collegeville, PA 19426
Money Order- All Money Orders are due one week prior to the start of class
Online Payment- Please see included link
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