Registration Form

GST BOCES

Registration Form

GST BOCES Adult Ed. and Training Services · Bush Campus . 459 Philo Road · Building #8 · Elmira, New York 14903-1089

 Date __________________________________

 Last Name _____________________________ First ________________________ M.I. ______

 Street Address _____________________ City/State/Zip ________________________________

 Date of Birth _______________________ E-mail Address ______________________________

 Home Phone _________________________ Social Security # ____________________________

 Authorizing Company ________________________________ Phone # ____________________

 Authorizing Dentist _________________________ Contact Name _______________________

 Billing Address _____________________ City/State/Zip _______________________________

 Payment Type:     Cash    Check    VISA    MC   Money Order   Company/Agency Bill

 Credit Card # ________________ Exp. Date _____________ Gold Card # ________________

 Course Number

   Course Title

 Module Number

      Cycle

Course Fee

           CDAMP      
         
         * Textbook?      
         
         

 

 

 

 

 

 All enrollees must be 18 years or older.

 *Using 3rd & 4th edition text books only.

  "Dental Assisting, A Comprehensive Approach", Phinney & Halstead

   

  Make check payable to GST BOCES. Do Not FAX .  

                                                                                                                                      

Created with the Teacher's Digital Toolbox, (c) Copyright August 2000, SCT BOCES, Elmira, NY, All Rights Reserved