Dental Assistant Application | Radiance Dental Assisting Academy

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Home Phone

Work Phone

Date of Birth

DD

MM

YYYY

Have you ever been convicted of a drug-related offense?

Yes
No

Emergency Contact Name

First Last

Emergency Contact Phone

Educational Data

Highest level of school completed

G.E.D. obtained?

Yes
No

Grad. Degree?

Yes
No

High School name and location

College name and location

Major

GPA

Subjects of special study

Special training and skills

References

Character References: Please provide three persons not related to you, whom you have known at least one year.

Reference #1 Name

First Last

Reference #1 Phone

Reference #2 Name

First Last

Reference #2 Phone

Reference #3 Name

First Last

Reference #3 Phone

May we contact your references?

Yes
No

What session are you interested in applying for?

Please state briefly why you wish to attend dental assisting school

Signature

I certify that all the information provided is complete and accurate to the best of my knowledge.

Applicant's Signature

Date

MM

DD

YYYY

CAPTCHA

Online Application

Dental Assisting Program

Educational Data

References

Signature