NJ State Radiology 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:

Have you taken our Introductory Dental Assisting course or an equivalent course elsewhere?

If you answered no to the last question, are you familiar with the eight items listed under prerequisites?

Course InformationCourse Title: Full Cost of Course:

Starting Date: Ending Date: Time of Course:

Please contact me if an earlier course date becomes available: Yes No

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

Additional NotificationThis course is approved by the Bureau of X-Ray Compliance (NJ Department of Environmental Protection). Taking a state approved course such as this one is required to obtain a dental x-ray license in the state of New Jersey. This course includes a didactic (instructional) component, a laboratory component, and a clinical component. All components must be completed successfully. This course also requires the additional purchase of a textbook.

Moral Character StatementThe Bureau of X-Ray Compliance requires that in order to become a limited dental radiologic technologist (that is, to get your dental x-ray license) you must "be of good moral character as determined by the Board". While every case in unique, if you have not engaged in any criminal behaviors such as felonies, misdemeanors, fraud, or falsification of documents you are probably "of good moral character". If you have engaged in one of these behaviors or something similar you should contact the Bureau directly.

The Bureau is not looking to prevent anyone who has ever had a run in with the law from finding work, but they do have specific criteria that they screen for. As each case is unique, if you are at all unsure of whether or not you would qualify as being "of good moral character", you should contact the Bureau directly at 609-984-5634.

Are you of good moral character?

Signature: ________________________________________

Date: ____________________

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.

Additionally a copy of your United States high school diploma or GED is required and should be mailed along with this registration form. If you attended high school and/or college outside of the United States, you must have your degree and/or transcript translated and evaluated. Click here for further information about how to do this.

ChecklistI have included my: Completed registration form $100 deposit Copy of my high school diploma or equivalent

Signature: ________________________________________

Date: ____________________