Complete Application to Enroll in Our Programs or Course of Interest Contact Us Step 1 of 2 - Student Application for Admissions 0% Name(Required) First Middle Last Phone(Required)Email Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Social Secuity # How did you hear about us? EDUCATION: ( If Applicable)HIgh School : Graduated? YES NO College / Tech. School: Did you receive a Degree/Diploma? YES NO FileMax. file size: 1 GB.Emergency Contact Information:Name:(Required) First Last Relationship: Phone Number:(Required) I wish to be considered for the acceptance of the following program:Dental Assisting - (full course)Radiology ONLYCoronal Polishing ONLYConsent By signing below I attest that all the information provided is true and accurate to my knowledge. I understand there will be a $100.00 Non-refundable deposit required prior to my official acceptance into the program.Signature:(Required) Date MM slash DD slash YYYY Name First Last Social Security Number:DOB: MM slash DD slash YYYY Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneMarital StatussinglemarrieddivorcedHave you ever worked in health care?YESNOHave you ever been convicted of felony?YesNoWhat were you doing when you decided to enroll in NIDA- National Institute of Dental Assisting? Employed Full-Time Employed Part-Time Self-employed Not employed but looking for work Not employed and not looking for work Homemaker Retired Student Prefer Not to Answer How did you hear about us? Online Google Yahoo Social Media Facebook Former student Friend/Family What were some of the reasons you chose to attend Dental Assisting School?(Required)What caused you to choose National Institute of Dental Assisting?Important Notice to Student Applicants(Required) Although we do not obtain a criminal background check in order to admit students into the program, students must be aware that certain employment opportunities in the health care industry may not be open to individuals with certain types of convictions. A criminal background check may be performed by prospective employers before being hired.Signature:(Required) Date MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
