Orthodontic Assisting Application Please enable JavaScript in your browser to complete this form.NameFirstLastAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthEmailHome / CellParent, Guardian, or Spouse NameParent, Guardian, or Spouse Home / Cell High School/College NameYear of Grad. Please Select High School GraduateGEDCollegeHow I heard about this programIn case of emergency contact:NamePhoneRelationshipState, ZipPlease select which class you would like to attendSession ISession IISession 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 $150.00Clear SignatureClick and drag to signSubmit