Contact NSDA Stockton:
P.O. Box 1535
Lathrop, CA 95330

Telephone Numbers:
209-403-6483 office
209-858-5208 fax

Upcoming Classes

• Saturday January 28, 2012

• Saturday April 28, 2012

• Saturday July 28, 2012

The content for our Dental Radiology course is approved and regulated by the State Dental Board of California.

Application For Enrollment

If you would like to download this application as a PDF to review and send in by mail click here. You will need Adobe Acrobat reader to view this form.

APPLICATIONS ARE ACCEPTED THROUGHOUT THE YEAR FOR ALL SESSIONS
Denotes required fields


First Name		Last Name

Street Address

City

State

Zip

Home Phone

Mobile Phone

Email

Date of Birth

Ever been convicted of a drug related offense?

Yes No

In case of emergency, whom should we contact?
Relation and Phone Number

EDUCATIONAL DATA

Highest Grade Completed

College

Graduate Degree

Yes No

High School Diploma or G.E.D.?

Yes No

Completion Date

EXPERIENCE

Please state briefly why you wish to attend dental assisting school:

Please describe any dental office experience you have had up to now:

Session applying for
Need a Catalog	Yes No

I certify that all the information provided is complete and accurate to the best of my knowledge.

Yes No

How did you hear about us?	If Other:
Additional Comments:

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