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Dental Assisting Application Form
Lamar State College-Orange Dental Assiting Program

Dental Assisting Application Form

I am applying for January Class of
August Class of
(Last) (First) (Middle) (Maiden)
(Number, Street)
(City) (State) (ZIP)
SSN (Social Security Number)
(Area Code) Number
If an emergency, contact
Have you ever been enrolled in a dental assisting program? YES NO
If Yes,
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.

Applicant's Signature and Date