Dental Assistant Registration

Timer

--:--

* = required field

Some content may be updated based on selection

Dental Assistant Program Registration Form
P.O. Box 1307 Mt. Pleasant, TX 75456-1307
Office 903-434-8134 | Fax 903-434-4408
continuinged@ntcc.edu

A $200 non-refundable deposit is due at time of registration to secure your spot in the upcoming class.

Student Information:

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Social Security Number:

Date of Birth:

Primary Phone:

Email Address:

Demographic Information:

Gender:

Ethnicity:

Class Date:

Work Information:

Are you a US Citizen?

Have you ever been convicted of a felony?

Education Information:

High School:

Address:

Dates (from-to):

Did you graduate?

College:

Address:

Dates (from-to):

Did you graduate?

Degree:

I understand that I will need to provide a copy of my valid driver's license/ID as well as a copy of my HS diploma/GED to Mount Pleasant Dental Assistant School in order to be registered for classes. Please send copies to info.mpdas@gmail.com.

Yes

This information I have provided is complete and correct to the best of my knowledge. I authorize the college to verify the information I have provided.

Agree

Disagree

Note: Payment for Continuing Education courses is due at the time of registration. You will receive an email after your form has been processed and you are registered (check your junk mail folder!). Please see our website for additional registration policies: CE Registration and Policies

Please wait for files to finish uploading