Orthodontic Assisting Application

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Date of Birth

Email

Home / Cell

Parent, Guardian, or Spouse Name

Parent, Guardian, or Spouse Home / Cell

High School/College Name

Year of Grad.

Please Select

High School Graduate
GED
College

How I heard about this program

In case of emergency contact:

Name

Phone

Relationship

State, Zip

Please select which class you would like to attend

Session I
Session II
Session III

I understand that there is a $40.00 nonrefundable application fee to be included as well as documentation of official high school transcript, official GED transcript, or official college transcript, we only need 1 official transcript. Without these two requirements my application will not be complete and sent back. Late fee is $150.00

Click and drag to sign

In case of emergency contact:

Happy Holidays!