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APPLICATION for Competitive Edge Dental Assisting Academy, LLC
"
*
" indicates required fields
CLASS
*
ASSISTING COURSE
CORONAL POLISHING
SEALANTS
NITROUS
(click all that apply):
Choose Assisting Course Start Date:
January 23, 2024
Select One
Coronal Polishing: Two day course with 14 CEs and must have current Tennessee RDA license ($295.00)
One day course with 6 CEs and must have current Tennessee RDA license ($245.00)
One day course with 5 CEs, must have a current Tennessee RDA license ($115.00)
Contact Info
Legal first and last name
*
First
Last
What name do you prefer to go by?
First
Email
*
Phone
*
DOB
*
MM slash DD slash YYYY
Address
*
Street Address
Unit
City
State / Province / Region
ZIP / Postal Code
Do you have a current US issued photo ID?
*
Driverโs License
Passport
Select One
Tennessee RDA#
*
Choose Your Course.
*
APPLICATION FEE (NON-Refundable) - $100
CORONAL POLISHING - $295
SEALANTS - $245
NITROUS - $115
Total
Payment Method
*
Credit/Debit
Check
Credit Card
Name
This field is for validation purposes and should be left unchanged.
APPLICATION for Competitive Edge Dental Assisting Academy, LLC
"
*
" indicates required fields
CLASS
*
ASSISTING COURSE
CORONAL POLISHING
SEALANTS
NITROUS
(click all that apply):
Choose Assisting Course Start Date:
January 23, 2024
Select One
Coronal Polishing: Two day course with 14 CEs and must have current Tennessee RDA license ($295.00)
One day course with 6 CEs and must have current Tennessee RDA license ($245.00)
One day course with 5 CEs, must have a current Tennessee RDA license ($115.00)
Contact Info
Legal first and last name
*
First
Last
What name do you prefer to go by?
First
Email
*
Phone
*
DOB
*
MM slash DD slash YYYY
Address
*
Street Address
Unit
City
State / Province / Region
ZIP / Postal Code
Do you have a current US issued photo ID?
*
Driverโs License
Passport
Select One
Tennessee RDA#
*
Choose Your Course.
*
APPLICATION FEE (NON-Refundable) - $100
CORONAL POLISHING - $295
SEALANTS - $245
NITROUS - $115
Total
Payment Method
*
Credit/Debit
Check
Credit Card
Comments
This field is for validation purposes and should be left unchanged.
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