Enrollment Paperwork
Continuing Education and Training
Registration Form
951-348-2631 | brandihackney@hotmail.com | http://brandihackney.wix.com/dental-assisting
Today’s Date____________ Last 4 Digits of Social Security No.____________ Date of Birth (required)__________
I am 16 yrs. or older
Last Name___________________________________________________________
First Name______________________________________ Middle Initial______
Home Address_________________________________________________________
Email Address___________________________________________________
City____________________________________ State________________________Zip________________
County of Residence_____________________________
Home Phone _____________________________ Business Phone __________________________________
Cell Phone___________________________________
Male Female
U.S. citizen
Other than U.S. citizen (pay course cost plus $10 out-of-state fee per course; fee waived with copy of appropriate Visa)
Course Title Start Date Cost
____________________________ _____________________________________________________ ______________ _
Out of County/Out of State Fees _____________
Total Cost _____________
E-Mail completed registration form to:
If paying with a credit card, please fill out the bottom portion of this registration form. PayPal is also an accepted method of payment.
The Family Educational Rights and Privacy Act (FERPA) protects the privacy of student records.
I certify that the statements made in this application are correct. I agree to comply with all policies and regulations of Comprehensive Dental Services’ online training program.
Signature (required)________________________________________________________________________________________________
For Office Use Only: Rec by ________________________ Processor_____________________ Date___________________
Phone E-mail
Charge to my: Amex Visa MC
Credit Card Number_________________________________________________________________________
CID#_____________________________________
Note: Your CID# is the last three digits in the signature box on the back of your credit card
Card Holder’s Name_________________________________________________________________________
Credit Card Expiration Date_____________________
Card Holder’s Billing Address (required)________________________________________________________________________________________________
Card Holder’s Signature________________________________________________________________________________________________
418-13-0613 FRM