Application for Dental Assisting Training Program

Application Instructions:

Complete all sections of application form
Upload passport-sized photo
Upload a copy of your high school diploma or equivalent
Once application is received, a payment link for the $100 application fee will be forwarded.

Please select which month you are applying for:

PERSONAL DATA

Name(Required)

First Middle Last

Current Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Citizenship(Required)

US Citizen

Permanent Resident

Foreign National

Visa Status(Required)

Country of Birth(Required)

Date of Birth(Required)

Male

Female

Scrubs Size

(Top)

(Bottom)

EDUCATION AND PROFESSIONAL BACKGROUND

High School & Graduation date(Required)

College

Additional Training

Passport-sized photo(Required)

Max. file size: 100 MB.

Upload a copy of your high school diploma or equivalent (Required)

Max. file size: 100 MB.

CERTIFICATION

The Dental Assisting Training Program (DATP) is available to individuals located, or those who intend to work as Dental Assistants, in the Commonwealth of Massachusetts. The clinical experience provided by the DATP meets the requirements necessary for initial licensure as a dental assistant trained on the job (OJT) in the Commonwealth of Massachusetts. Additional requirements for on-the-job training licensure include, but are not limited to examinations, additional certifications, background checks, etc. This program does not meet the Massachusetts licensure requirements for the EDFA or CDA, and is not CODA accredited. For more information on licensure requirements, please visit the Massachusetts’s Board of Registration in Dentistry https://www.mass.gov/orgs/board-of-registration-in-dentistry. Applicants who fail to submit all necessary documents for consideration may be excluded from the acceptance process. It is the responsibility of the applicant to ensure that all pertinent records have been received by Continuing Education. I understand that it is my responsibility to ensure that all pertinent records have been submitted to and received by Continuing Education at GSDM and further that if I fail to submit all necessary documents for consideration, I may be excluded from the acceptance review process. By signing below I am confirming that all of the statements made by me in this form are complete, true, and accurate to the best of my knowledge. I understand that falsification of any of the information contained in my application credentials, including this form, may subject me to elimination from any further consideration by the acceptance committee and/or dismissal from the Dental Assistant Training Program.

Signature(Required)

Date(Required)