Dental Assistant Pro Online Enrollment Agreement

"*" indicates required fields

Student Name*

First Last

Dental Assistant Pro Registration Fee

Price:

To complete your registration please pay the registration fee of $125 using the secure payment portal below.

Dental Assistant Pro Registration Fee

Price:

To complete your registration please pay the registration fee of $1 using the secure payment portal below.

Total

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email (for payment confirmation)*

Name

This field is for validation purposes and should be left unchanged.