Jamaica Registration

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.

REGISTRATION FORM

* Indicates required field

Applicant Name *

First

Last

Applicant Email *

Phone Number *

Work Phone Number *

Choose the Course Date *

Mar 6–10, 2019 · Option 1 June 12–16, 2019 · Option 2 Nov 6–10, 2019. Option 3

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date Of Birth *

Place Of Birth *

Nationality *

Degree or Diploma *

Date Granted *

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

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 *

If YES, for what reason, and on what date? *

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? *

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 *

REGISTRATION FOR 5-DAY SEMINAR IN JAMAICA

Registration Process

REGISTRATION FORM