REGISTRATION FORM - RDA WRITTEN EXAMINATION REVIEW SEMINAR

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Social Security _________________________
Address_____________________________________________________________________
City ________________________________________________
State________      Zip __________
Employer ___________________________________
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Seminar Fee: $170, includes course, manual and study questions

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


Course Name: RDA Written Examination Review Seminar
Course Fee: $170,includes course, manual and study questions
Location:
Number:
Date:

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

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Provide the 3 or 4 digit code that is on the back of your credit card _____

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