Dental Assistant l Registration Application

First Name *

Last Name *

Date of Birth *

Gender *

Email *

Phone *

Address

Street Address *

City *

State *

Country

Postal code *

Emergency contact name *

Emergency contact phone number *

How did you learn about the DA Academy of NC? *

What interests you about the Dental industry? *

Why is right now a good time to go to school and start / change your career ? *

Who would be most proud of you upon graduating from DAANC ? *

HS, College or GED information; list the School Name, Graduation month and year, City and State *

Any education after high school? If yes, list school name(s) and credentials below. Leave blank if not applicable.

What kind of student would you consider yourself? *

Are you currently employed? *

Yes

No

Place of Employment

How long have you been employed? Current hourly wage:

What is your current work schedule?

If unemployed, how long?

If you are job searching, what are your challenges?

What previous jobs have you had in your past? Share some duties / responsibilities

Will you continue to seek employment while attending school? *

Yes

No

Unsure

Give three reasons why you are a good fit for DAANC? *

While attending, will you commit to your studies, complete your program, and graduate from DAANC? *

Yes

No

How do you plan to pay for the cost of tuition? If you are doing a down payment, select the frequency: *

One Payment in Full

Weekly Payments

Bi-Weekly Payments

Funding

Supporting Document(s) Upload you also have the option to submit your completed transcript separately via website or by sending to email : [email protected]. Please understand that failure to do so may delay processing your application.

Upload : Completed (High school, College or GED) Transcript, ID (License or passport) and Social Security Card

Signature *

Clear

Today's Date *

DA l Application Fee *

$ 103.5

$3.50 Processing

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Call
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Email:

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