Form

Florida Dental Radiography Application for Admission

Full Name

Date

Address

City

Zip Code

Phone

Date Of Birth

Age

Sex

If you have a dental radiography certification from another state, please upload a copy of your certification.

Upload or drag files here

Dentists initials and signature are required below verifying the following two items:

If you do not have a dental radiography certification from another state, but have had a minimum of three (3) months of continuous on-the-job dental assisting training, check the boxes below.

Florida Licensed Dentist

License Number:

Dentist Signature

Date

Check below to certify that the following is true.

Applicant Signature

Date

Please Note: Bartram Dental Assisting School is not affiliated with any other public or private university or college in Florida or elsewhere. Upon completion of coursework, Bartram Dental Assisting School does not guarantee employment or salary in a given field of study. Any jobs or salaries mentioned are given as examples of potential employment, not a representation of a guaranteed income.