Dental Assistant Training Application

First Name *

Middle Initial *

Last Name *

Address *

Permanent address preferred

County *

Date of Birth *

Month

Day

Year

Country of Birth *

Social Security Number *

List n/a if unavailable.

Gender *

Are you of Hispanic, Latino, or Spanish origin? *

Yes

No

What is your race? Select one or more. *

Do you have U.S. Military experience? *

Yes

No

Education

Provide your high school or GED information below. The program coordinator will provide information on submitting official transcripts/certificates to UKCD.

Name of High School

Date GED Received

Month

Day

Year

Source

How did you hear about our training?

Application Fee

Click the Apply button below to enter payment information for the nonrefundable application fee of $25. Payment must be made at time of application submission in order for an application to be reviewed.

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