PRODUCT ORDER FORM - RDA PRACTICAL EXAMINATION KIT

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

Product Order Form
Product: RDA Exam Kit Rental Only (Southern CA only)
Please check choice of kit:

Complete Kit: $60 _____ Typodont Kit Set-Up: $40 _______
**Candidates must bring gloves, safety glasses, mask and flashlight.

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

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 _______________________