ORDER FORM - EXAM HOME STUDY PROGRAM

Name (please print) ________________________________
Address_____________________________________________________________________
City ________________________________________________
State________      Zip __________
Employer ___________________________________
Home Telephone (   ) _________________   Fax (  )_______________
Work Telephone (   )__________________   E-Mail_________________

In order to process your request, please print clearly the following information and complete all spaces where applicable.

Product Order Form
Please send me:
_____ Written Questions/Review Manual $85
_____ Written Review Manual Only $55
_____ Practical Video-Workbook-Model Only (supplies and materials not included) $125

               Please Select Your Preference:   ___DVD   ___VCR

If payment is made via mail system, make money order payable to:
Dental Professionals of California
3144 North G Street, Suite 125-318, Merced, CA 95340

For Visa/Master Card Order Only
Name on Card _______________________________
Card Number ________________________________
Expiration Date_____________________________
Provide the 3 or 4 digit code that is on the back of your credit card _____

Authorized Signature _______________________