Commission on Ohio Dental Assistants Certification, Inc.
	Examination Application Please Print Or Type

Last Name _________________________First Name ___________________Middle Initial ______
Address ___________________________City _______________________State Ohio Zip_______
Phone (Include Area Code) Home(____)__________________Work (____)_________________
Date of Birth: Month ______Day ______Year_____SS Number:_____________________________
Are you currently enrolled in a Dental Assistng Program?   Yes___  No___
Type of Program:  High School ___ Post Secondary ___ Date of Completion _______________
Date or Examination you are applying for: ______________________________________________
Have you applied for this examination previously? Yes _____ No _____ Date of exam you are applying for _______
Have you taken this examination previously?------- Yes ____ No _____
Type of exam applying for (check one)
Full Exam ___   Retake: Written ____  Clinical ____  Radiology ____

If applying to retake any portion of the exam complete the following:
Date(s) exam previously taken Month _______ Year _______ Last name at time of application__________________
If you have failed the exam three times you must submit proof of additional education before retaking the exam the fourth time.

I hereby certify that the above is true and I grant permission to release information pertaining to my certification.

Signature of Applicant _______________________________________Date __________________

CHECK ALL ITEMS THAT ARE ENCLOSED WITH APPLICATION
----------TWO IDENTICAL 2"X2" (PASSPORT TYPE) PHOTOGRAPHS OF YOURSELF TAKEN
______NOT MORE THAN SIX MONTHS BEFORE THE APPLICATION IS SUBMITTED.
______COPY OF CURRENT CPR CERTIFICATION
______ETHICAL CONDUCT REQUIREMENT (CHOOSE ONE OF THE FOLLOWING A,B,or C)
A. THREE NOTARIZED letters to verify your ethical condust from member of any of the following:
American Dental Association or
American or National Dental Assistants Association or
American or National Dental Hygienists Association

B. Copy of your current membership card in on of the above named Associations.

C. Students currently enrolled in Dental Assisting Program
ONE NOTARIZED LETTER FROM YOUR INSTRUCTOR

D. I have taken the exam within the last twelve months and my letters are on file
FEE (check one)
_____$50.00 for Full Exam
_____$40.00 for Retake 
_____$5.00 Reprocessing (if you have applied but not taken the exam within the last twelve months.

.
Persons with disabilities who need assistance are asked to notify the Commission at the time of application

This form was generated from the CDAS website