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Classroom Rental
Course Registration form
Course Registration form
Email
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Name
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First
Last
Your Phone Number:
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Course
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Choose
First Choice
Second Choice
Third Choice
Course Cost
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Choose
First Choice
Second Choice
Third Choice
Payment Method
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Check- Payable to FORT BEND DENTAL ACADEMY
ACH- Contact for Details
Cash
PayPal
For Bend Dental Employee
Other:
Today's Date:
(Required)
DD slash MM slash YYYY
Are there any prerequisites listed for this course? If YES, please be sure to attache your proof of required training needed for course. If NO, please put N/A. N/A
(Required)
Yes
No
Please upload proof of prerequisite required for course if applicable.
Max. file size: 10 MB.
Please upload your dental license if required by course. (DDS, RDA, RDH, CDT)
Max. file size: 100 MB.
Upload up to 5 supported files. Max 100 MB per file.
Please upload you malpractice insurance. (Live Patient Courses Only.)
Max. file size: 10 MB.
Upload 1 supported file. Max 10 MB.
Does this course state that you will need specific equipment to participate?*
(Required)
Yes
No
I understand by clicking YES to this question I am required to bring specific equipment to this course. By clicking NO I understand specific equipment is not needed.
(Required)
Yes
No
Please pick what audience you are apart of?
(Required)
General Dentist
Specialty Dentist
RDH
RDA
Front Desk/Admin
CDT/Lab
Student
Other
I, the undersigned, verify that this registration form is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provide the needed information and required documentation could likely lead to delays in the processing of my registration. By clicking the "yes" bottom below, I acknowledge that I understand I am registering for continuing education courses and that upon successful completion of certain courses I will be awarded and receive a CE certificate with the corresponding hours of awarded education. I further understand that the cost of course to secure my seat will need to be paid after completing the registration form by ACH, Paypal, cash, or check made out to Fort Bend Dental Academy to secure seat. Just because I fill out this registration form does not mean I am automatically enrolled in the course.
(Required)
I agree to the privacy policy.
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