Dental Assistant l Registration Application

At D.A. Academy of North Carolina, we see your potential—and we're here to help you turn it into a fulfilling dental career. Let’s get started! Please fill out this form entirely and carefully for registration.

Select the session that you are applying for: *

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Sex: *

Address

Street Address *

City *

State *

Country

Postal code *

Educational Background: HS, College or GED information- Please list the School Name, Graduation month and year, City and State *

Any education after high school? If yes, list school name(s) and credentials below. Leave blank if not applicable.

Optional Supporting Document(s) Upload:

Upload Your: 1. Completed (High school, College or GED) Transcript, 2. ID (License or passport) and 3. Social Security Card

Signature *

Clear

Today's Date *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to 704-529-9177 for assistance. You can reply STOP to unsubscribe at any time.