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: [email protected]

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

______Name (Last) (First) (Middle)

______Home Address City, State, Zip

______Home Telephone Cell Phone Email

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

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

Prosthetic in Memphis, TN at UTHSC Campus ($2,775.00 per attendee)

 April 3 - 6, 2017 –week one; May 8 - 11, 2017 – week two

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

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

 MC  VISA  DISCOVER

______V Code______Check/Card Number Expiration Date

______Cardholder Signature

2017 EFDA Memphis Prosthetic Application EMPLOYMENT INFORMATION (provide 2 years of employment. Use additional paper if necessary.)

______Dental Office Name (present employer)

______Doctor’s Name

______Office Address

______City, State, Zip Office Telephone Dates of Employment

______Dental Office Name

______Doctor’s Name

______Office Address

______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.

______Applicant’s Signature Date

______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.