Expanded Functions 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:    I am planning to take this course:

If other, please specify:

Do you already have a CDA

(or COA

) certificate?

When did you or do you plan to obtain your certification?

Course InformationCourse Title: Full Cost of Course:

Starting Date: Ending Date: Time of Course:

Payment InformationA $100 non-refundable deposit is required along with this registration form. The remaining balance is due on the first day of class. Please call us at 732-919-1816 for current rates when filling out the cost in the above section.

Legal Notice By checking the box below I am indicating that I have read and agree to all the terms and conditions as well as the copyright notice. 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 $100 non-refundable deposit made out to Dental Assistant Services in order to reserve your seat in the course. Alternatively, you may bring this form and your deposit to our office in person. This registration form must be filled out completely. You will be called one week prior to the start of class to confirm your registration. Click here for further registration instructions.

Signature: ________________________________________

Date: ____________________