Course Title:__________________________________________________________________


Course Date:________________________________Amount Enclosed:___________________
                                                                                                                (TUITION & BOOKS)

Your Legal Name:_____________________________________________________________
                                          (Your name as it appears on your legal identification)
                                        
Home Address:_________________________________________________________________
                    (Street)                                                   (City)                          (State)            (Zip)

Home Phone:__________________SocSecNo:___________High School Grad ____Yes____No
                                                                      (Last 4 Only)

Dentist’s Name:____________________________________Phone Number:________________


Address:______________________________________________________________________
                  (Street)                                                     (City)                           (State)           (Zip)

Fax:_________________________________Previous Experience:________________________


EMPLOYING DENTIST PLEASE COMPLETE THE FOLLOWING:
This employee has been working for ____months ____years in the dental office and I agree to provide clinical experience
under my in room supervision. I agree to evaluate the applicant’s performance. Once the course is completed the
assistant may not continue to perform these duties until the required boards are passed and state certificate received.


________________________________________________________________________________________
(Dentist’s Signature)                                                                                      (Date)

TO REGISTER : Complete the information above and return it 10 days prior to the starting date along with your payment
to: Southern Maryland Dental Society, 4920 Niagara Road, Suite 306, College Park, Maryland 20740. All courses and
book packages must be paid for in full in order to take the course. Refunds can only be given if you withdraw 10 days
prior to the first class.  A $30.00 administration fee will be charged for your refunds or transfers.  Books can be picked
up during regular office hours once registration and payment is complete.  Classes are held in Suite 304 at this same
address unless otherwise indicated.  Checks are to be made payable to the Southern Maryland Dental Society (SMDS).
We do not take credit cards.  For additional information contact Janice Farber at 301-345-4196.


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COURSE APPLICATION
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Southern Maryland Dental Society
4920 Niagara Road, Suite 306
College Park, Maryland 20740
301-345-4196
Fax: 301-345-0016
NOTE: HANDOUTS FOR CLASS ARE INCLUDED IN THE BOOK PACKAGE.