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(657) ADIS-4-ME
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DENTAL IMPLANTS CONTINUING EDUCATION
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Implant course 3+3
Registration
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CBCT
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AAIP Fellowship Exam
AAIP Application
Course Evaluation
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Home
Implant course 3+3
Registration
Payment
Contact Us
Faculty
CBCT
Review
AAIP Fellowship Exam
AAIP Application
Course Evaluation
News
REGISTRATION FOR 5-DAY SEMINAR IN JAMAICA
Registration Process
Fill up the Registration form below.
Make a payment
— minimal deposit of $1,000 is required at the time of registration to reserve your space.
Schedule telephone interview
(657) ADIS-4-ME
REGISTRATION FORM
*
Indicates required field
Applicant Name
*
First
Last
Type the name, as you wanted on your certificate
Applicant Email
*
Phone Number
*
Contact ADIS for dates
*
Work Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date Of Birth
*
Place Of Birth
*
Nationality
*
Degree or Diploma
*
Date Granted
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Institution
*
Address
*
Postgraduate Qualifications
*
Copy of your current license
*
Max file size: 20MB
Upload a photocopy of current passport
*
Max file size: 20MB
Photocopy of your diploma
*
Max file size: 20MB
Participant's Photo
*
Max file size: 20MB
Resent Photo, selfy is OK.
Has your registration or entitlement to practice as a Dentist ever been cancelled or suspended? ENTER YES OR NO. If you enter YES, for what reason, and on what date?
*
Yes
No
OTHER COUNTRIES OR INSTITUTIONS, (in which you have practiced, Please enter dates, If None enter NONE
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If YES, for what reason, and on what date?
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Names and addresses (e-mail), phone number's of three (3) character referees.
Name: character referee 1
*
First
Last
Phone Number 1
*
Email 1
*
Name character referee 2
*
First
Last
Phone Number 2
*
Email 2
*
Name character referee 3
*
First
Last
Phone Number 3
*
Email 3
*
Do you have any dietary restrictions?
*
None
Kosher
Vegetarian
Vegan
To hereby apply to be registered as a Dentist and declare that am the person named in the enclosed diplomas or certificates and that the above information is true and correct, ENTER YOUR NAME TO CONFIRM; I agree to use electronic records and signatures
*
Todays Date
*
Comment
*
REGISTER