Lamar State College-Orange Dental Assiting Program

Dental Assisting Application Form

I am applying for January Class of ____________
August Class of ____________
Name (Last) (First) (Middle) (Maiden) ___________________________________________________________________________
Address (Number, Street) ___________________________________________________________________________
Address (City) (State) (ZIP) ___________________________________________________________________________
SSN (Social Security Number) ___________________________________________________________________________
Telephone (Area Code) Number ___________________________________________________________________________
If an emergency, contact (Name) ___________________________________________________________________________
Have you ever been enrolled in a dental assisting program? Yes ____________ No ____________
If Yes, (Where) _____________________________________________________ Year _____________
If you did not complete the program, please explain ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

THEA test not required for dental assisting program certificate.
THEA SCORES, if taken:

 

Reading ____________ Writing ____________ Math ____________

Do you have a certificate in radiology? Yes ____________ No ____________
Certification Number ________________________
Certification State ____________ Expiration Date ____________

I certify that the above statements are true.

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Applicant's Signature and Date