General Chairside Registration Form

Contact Information

Full Name:     Phone number:     Type:  Home Work Cell

Address:     Phone number:     Type:  Home Work Cell

City:     State:  AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY    Zip Code:     Email:    

Last four digits of Social Security Number:     Do you have a valid CPR certificate?  Yes No

*It is a DANB requirement that prior to taking the General Chairside exam you have at least 3500 hours of work experience as a dental assistant in at least two years and in no more than a four year period at any point in your career.

Currently I have  less than 500 500-999 1000-1999 2000-2999 3000-3499 3500 or more   hours of experience.

With respect to the DANB requirement:

  I already meet the requirement and will still meet it when I take the exam.
  Although I do not meet the requirement today, I am on pace to meet the requirement before I take the exam. 
  I do not meet the requirement today, but should be able to meet it within the next year 2 years 3 years 4 years or more