Dental Assistant Course Registration Form (11)

September 12 - 13, 2008 Registration Form

8:00 – 5:00 P.M. Arlington, Texas

Please print & complete one form for each participant.

Name: _______________________________________________________________

Address: ______________________________________________________________

_____________________________________________________________________

City/State/Zip: ________________________________________________________

Home No: ____________________________________________________________

Work No: _____________________________________________________________

Fax No: ______________________________________________________________

Cell No: ______________________________________________________________

Email: (required to receive Study Materials): __________________________________

Payment Options: Money Order, Business (Employer’s) Checks or Cashier’s Checks only.

NO personal checks will be accepted at this time.

Check Number: __________ Payable to: DCDAS Amount Enclosed: ____________

This two (2) day course is $225.00, which includes printed materials and the Examination. Participants MUST bring: A Photo ID, along with pens, highlighters, and notepaper.

DCDAS’s Exam Policy: Participants MUST attend both days. Participants may retake the examination up to one (1) time ($30.00) at the convenience of TDAA. If the participant does not successfully pass after the second (2^nd) try, the course MUST be retaken. NO PERSONAL CHECKS will be accepted.

Registration Deadline: Register early for attendance is limited. The deadline for registration is September 8, 2008. Confirmation and Study Materials will be sent to those who have an E-mail address and Register by the deadline.

Cancellation/Refund Policy: Cancellation/Refund Deadline is: September 8, 2008. Send written request for cancellation or refund to: Dallas County Dental Assistants Society (DCDAS), 2557 Brandywine Drive, Farmers Branch, Texas 75234. No refunds will be given after the stated deadline without the approval of TDAA Board of Directors. Refunds will be processed three weeks after the program date, but subject to a 25% administrative fee.

Mail Registration Form with payment to:

Dallas County Dental Assistants Society (DCDAS)

2557 Brandywine Drive

Farmers Branch, Texas 75234

For additional questions please call: 1.972.247.6659