University of Tennessee College of Dentistry

UNIVERSITY OF TENNESSEE COLLEGE OF DENTISTRY

2017 EXPANDED FUNCTIONS FOR DENTAL AUXILIARY

This is a limited attendance course. *Applications will be accepted in order of receipt.* Upon licensure confirmation with the TN Board of Dentistry, a $500 deposit is due for the first 32 applicants to ensure their registration. Final payment is due one month prior to start of course.
Return Application & Deposit:
Email:

Questions regarding the Expanded Functions courses should be directed to the Department of Continuing Education in the College of Dentistry, office (901) 448-5386.

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Name (Last) (First) (Middle)

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Home Address City, State, Zip

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Home Telephone Cell Phone Email

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SSN Last 4 Digits TN License/Registration Number Date of Registration

Please choose the certification course and session you wish to enroll.

Restorative in Memphis, TN at UTHSC Campus

($3,775.00 per attendee)

o January 09-12, 2017 –week one; February 13-16, 2017 –week two; March 13-16, 2017 –week three

PAYMENT INFORMATION (pay by check, MasterCard, VISA, or Discover)

o Charge my card full amount due. o Charge $500 deposit and send bill for the amount due.

o MC o VISA o DISCOVER

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Check/Card Number Expiration Date

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Cardholder Signature

EMPLOYMENT INFORMATION (provide 2 years of employment. Use additional paper if necessary.)

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Dental Office Name (present employer)

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Doctor’s Name

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Office Address

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City, State, Zip Office Telephone Dates of Employment

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Dental Office Name

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Doctor’s Name

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Office Address

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City, State, Zip Office Telephone Dates of Employment

IMPORTANT - THIS FORM MUST BE SIGNED BY THE INDIVIDUAL & EMPLOYER DENTIST

By signing this application, I and my employer dentist attest to the fact that I have been a Tennessee registered dental hygienist or dental assistant as defined in Rules 0460-03-.01 and 0460-04-.04, with a minimum of two (2) years continuous full-time employment within the past three (3) years in a dental practice as a registered dental assistant.

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Applicant’s Signature Date

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Attest - Employer Dentist’s Signature Date

*IMPORTANT*

Application and $500 deposit is due eight weeks prior to start of course. Final payment is 30 days prior to start of course. Cancellations made less than eight weeks prior to start of course will forfeit deposit.

2017 EFDA Memphis Restorative Application