Commission on Ohio Dental Assistants Certification, Inc.

Re-certification Application

NAME:______________________________________CERTIFICATION #_____________

ADDRESS:_____________________CITY:_______________STATE_____ZIP__________

PHONE:______________________SOCIAL SECURITY#___________________________

CONTINUING EDUCATION HOURS

TITLE OF COURSE DATES SPONSOR # HOURS SPEAKER
         
         
         
         
         
         
         
         
         
         
         
         
SUBMIT BY OCTOBER 31 TOTAL HOURS TO DATE____________
SIGNATURE:____________________________ DATE:____________________

FEE: $20.00 PAYABLE TO: Commission on Ohio Dental Assistant Certification, Inc.

Mail to: Commission on Ohio Dental Assistant Certification Re-certification
  %1501 Centerview Dr.
  Copley, OH 44321

THIS FORM WAS GENERATED FROM THE CDAS WEB SITE