Continuing Dental Education Course Registration Form

Dental Assistant Services
1306 Highway 33, Suite 3A
Farmingdale, NJ 07727
732-919-1816

Contact InformationFull Name:    Phone number:    Type:

Address:    Phone number:    Type:

City:    State:    Zip Code:    Email:

Last four digits of Social Security Number:

Course InformationCourse Title: Type of Course: Cost of Course:

If registering for a live course, please complete the following:

Date of Course: Time of Course:

Legal NoticeBy checking the box below I am indicating that I have read and agree to the terms and conditions of purchase for continuing dental education courses. Note: This check box must be marked or you will not be permitted to register for this course.

I agree and consent

InstructionsAfter filling out this form, please print it out. Sign and date the form below and mail it to the address at the top of the page, along with your payment made out to Dental Assistant Services. Alternatively, you may bring this form to our office in person. This registration form must be filled out completely. Home study courses are typically mailed out within a week. If you're registering for a live course, you will be called at least 48 hours prior to the course date to confirm your registration. Click here for further registration instructions.

Signature: ________________________________________

Date: ____________________