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ASAP Dental Assistant Program

Reliable. Professional. Friendly.

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First name

Last name

Email

Phone

Permanent Address

Current Address (if different than above)

Date of Birth

Age

What year did you receive your high school diploma or GED?

Name of High School (if applicable)

City, State where you attended high school

Name of former college and/or technical school (if applicable)

If you listed a college or technical school above, what year did you graduate?

How did you hear about us?

Word of Mouth

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Google

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What are you interested in?

DA 1 Program

Continuing Education

Other

What is your ethnicity?

Black

White

Hispanic

Other

What is your availability?

Nights

Fridays

Saturdays

Other

Did you pay your $200 deposit?

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ASAP Dental Assistant Program

Reliable. Professional. Friendly.

Contact

2607 E 7th Street Suite 102

Charlotte NC, 28204

Call or Text: 704-954-9348

Email: asapdentalassistantprogram@outlook.com

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