REGISTRATION FORM -
RDA PRACTICAL EXAMINATION REVIEW SEMINAR
Name (please print)
________________________________
Social Security _________________________
Address_____________________________________________________________________
City ________________________________________________
State________ Zip __________
Employer ___________________________________
Home Telephone ( ) _________________ Fax ( )________________
Work Telephone ( )__________________ E-Mail _________________
Course Fee: $130
In order to process your
request, please print clearly the above
information and complete all spaces where applicable.
Course Name: RDA Practical Examination Review Seminar
(Please Check Choice)
Course Fee: $130
Course Fee and Exam Kit Rental: $190
Location:
Number:
Date/s:
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 _______________________