Enrollment Agreement - AS4U Career Center ? AS4U CAREER CENTER PROVIDES A PROVEN AND STANDARDIZED CURRICULUM

Enrollment Requirements

Applicants Name*
Email*
Address (billing address)*
Street Address Address Line 2 City State ZIP Code
Social Security Number
Home Phone
Cellphone
Work Phone
Date of Birth
Have you ever been convicted of a drug-related offense?
- Yes
- No
In case of emergency, whom should we contact?
Name
Phone
EDUCATIONAL DATA
Check the highest grade completed
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- College - Fresh
- College - Sophomore
- College - JR
- College - SR
- Graduate
Degree
- Yes
- No
Do you have a high school diploma or G.E.D.?
- Yes
- No
Completion Date

School Name	Location	Graduate? (Yes or No)	Major	GPA

Subjects of Special Study
Special Training and Skills
EXPERIENCE
Please state briefly why you wish to attend dental assisting school
Please describe any dental office experience you have had up to now
Give the names of three persons not related to you, whom you have known at least one year.

References

Name	Address	Phone	Business

Do you authorize AS4U Career Center to contact your references?
- Yes
- No
Certification*
By checking this box or signing your name on this form, you signify and affirm that you are the person whose name appears above and the information contained in the form is true, correct and complete to the best of your knowledge and belief.
Applicant’s Signature
Date

X

Ready to pursue a career as a dental assistant?

Tuition as Low as $78/Month!

Our next class session starts 06/1/2019

Call to enroll today! 770.407.8700

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