*CAREER CHOICE:
THE ART OF CLINICAL CHAIRSIDE DENTAL ASSISTING

*SESSION APPLYIN FOR: 2010 Session 3 --- Jun 26 - Sep 18 2010 Session 4 --- Sep 25 - Dec 18 2011 Session 1 ---Jan 8 - Mar 26 2011 Session 2 ---Apr 2 - Jun 19 2011 Session 3 ---Jun 25 - Sep 17 2011 Session 4 ---Sep 24 - Dec 17 2012 Session 1 ---Jan 7 - Mar 24 2012 Session 2 ---Mar 31 - Jun 16 2012 Session 3 ---Jun 23 - Sep 15 2012 Session 4 ---Sep 22 - Dec 15 2013 Session 1 ---Jan 5 - Mar 23 2013 Session 2 ---Mar 30 - Jun 15 2013 Session 3 ---Jun 22 - Sep 14 2013 Session 4 ---Sep 21 - Dec 14 2014 Session 1 ---Jan 4 - Mar 22 2014 Session 2 ---Mar 29 - Jun 14 2014 Session 3 ---Jun 21 - Sep 13 2014 Session 4 ---Sep 20 - Dec 13 2015 Session 1 ---Jan 3 - Mar 21 2015 Session 2 ---Mar 28 - Jun 13 2015 Session 3 ---Jun 20 - Sep 12 2015 Session 4 ---Sep 19 - Dec 12

THE ART OF DENTAL OFFICE ADMINISTRATION

*SESSION APPLYIN FOR: 2010 Session 3 --- Jun 28 - Sep 2 2010 Session 4 --- Sep 27 - Dec 2 2011 Session 1 ---Jan 3 - Mar 10 2011 Session 2 ---Mar 28 - Jun 2 2011 Session 3 ---Jun 27 - Sep 1 2011 Session 4 ---Sep 26 - Dec 1 2012 Session 1 ---Jan 2 - Mar 8 2012 Session 2 ---Mar 26 - May 31 2012 Session 3 ---Jun 28 - Sep 2 2012 Session 4 ---Sep 27 - Dec 2 2013 Session 1 ---Jan 7 - Mar 14 2013 Session 2 ---Apr 1 - Jun 6 2013 Session 3 ---Jul 1 - Sep 5 2013 Session 4 ---Sep 30 - Dec 5 2014 Session 1 ---Jan 6 - Mar 13 2014 Session 2 ---Mar 31 - Jun 5 2014 Session 3 ---Jun 30 - Sep 4 2014 Session 4 ---Sep 29 - Dec 4 2015 Session 1 ---Jan 5 - Mar 12 2015 Session 2 ---Mar 30 - Jun 4 2015 Session 3 ---Jun 29 - Sep 3 2015 Session 4 ---Sep 28 - Dec 3

First Name:

Last Name:

Street:

City:

State: Zip:

Home Phone:

Work Phone:

Email:

Date of Birth:

Have you ever been convicted of a drug related offense: Yes No

Emergency Contact Information

First Name:

Last Name:

Relation:

Phone:

Educational Background

College: N/A Freshman Sophomore Junior Senior Graduate Degree: Yes No

High School Diploma / G.E.D: Yes NoCompletion Date:

High School Name, Location, Major, GPA, Graduation Date:

College Name, Location, Major, GPA, Graduation Date:

Other (please specify):

Please state why you wish to attend the Hawaii School of Dental Arts:

Please describe any dental office experiences:

References (Please provide the names and contact information of three persons NOT related to you whom you have known at least one year)

Character Reference 1: (Name, Business, Address, Phone)

Character Reference 2: (Name, Business, Address, Phone)

Character Reference 3: (Name, Business, Address, Phone)

Do you authorize HSDA to contact your references? Yes No

I certify that all the information provided is complete and accurate to the best of my knowledge:
Yes No

How did you hear about us?

Additional Comments: