Enrollment Agreement Enrollment Requirements Applicants Name* Email* Address (billing address)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PhoneEDUCATIONAL DATACheck 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 NameLocationGraduate? (Yes or No)MajorGPA Subjects of Special StudySpecial Training and SkillsEXPERIENCEPlease state briefly why you wish to attend dental assisting schoolPlease describe any dental office experience you have had up to nowGive the names of three persons not related to you, whom you have known at least one year.ReferencesNameAddressPhoneBusiness Do you authorize AS4U Career Center to contact your references? Yes No Some Enrollment Requirements: Must have a high school diploma or GED State-Issued Driver’s License, Military ID, State-Issued Identification Card, or US Passport (Photo ID for proof of identity) $100 Registration Fee(Non Refundable)& Background Check required.(Money Order, Credit Card, Cash) Students must have at least first shot in a series of 3 for the Hepatitis Immunization (Can be obtained by Health Dept,or any Urgent Care, Family Physician). Please see Payment Options and Refund Policy. 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.Tuition and FeesTuition* Full tuition: $3895 Down payment option: $500 Down payment option: $650 Down payment option: $800 Choose either full tuition, or choose a down payment option that works best for you.Registration Fee* Price: Total $0.00 Cancellation and Refund Policy The school must refund all money paid if the applicant is not accepted. This includes instanceswhere a starting class is canceled by the school. The school must refund all money paid if the applicant cancels by midnight of the third business day after signing the contract (Enrollment Agreement). The cost of material, equipment, books and uniforms provided to the student may not be refunded unless the items and materials in question are returned in “as new” condition. The school may retain one hundred dollars and the $100 Registration Fee and the cost of anyequipment, uniforms, books and material that is not returned in as new condition, if the applicantcancels after the third business day after signing the contract. Refunds are made according to the percentage of clock hours of classes attended and anymaterials, equipment, books and uniforms that is not returned in “as new” conditions. Effective date of termination for refunds purposes is the earlier of the last date of attendance or receipt of written notice of termination. Refunds are provided within 30 days of termination. The $100 application and background check fee, also known as Registrations fee,are not refundable under any circumstances. The cost of materials, equipment, books and uniforms provided to the student may not be refunded unless the items and materials in question are returnedin “as new” condition. Refunds will be prorated according to the amount of class time attended up t0 50%. No refund will be issued after completion of 50% of the course program. Applicant’s Signature Reset signature Signature locked. Reset to sign again Date Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name