Dental Assisting Enrollment Agreement

First Name *

Middle Name

Last Name *

Address *

City *

State *

Zip Code *

Citizenship *

SSN *

DOB *

Race *

Sex *

Phone *

E-mail *

E-mail Confirm*

Password *

Password confirm*

DENTAL Class *

I, , have read and agree to the terms

I agree to pay $500.00 not refundable deposit.

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Please do not try to register multiple times! After the first registration, try to log in and, if not,

call the support service (303) 752-0000 ext 14