American Society of Master Dental Prosthologists, Inc.
146-21  13^th  Avenue
 Whitestone, NY  11357
(718) 746-8355

Application Form for the onsite MASTER COURSE
of Dentistry for Continuing Education Courses  ASMDT Program.

Please check which location you would like to attend.
____	NEW YORK CITY	____	NORTHEAST	____	MIDWEST / CANADA
	(at NYU School)	____	SOUTHEAST	____	WEST COAST

CHAIRMAN

Vincent V. Alleluia, M.D.T., T.F.

PRESIDENT ELECT

Paul Federico, M.D.T.

VICE PRESIDENT

Paul Eliason, MDT, TF

EXECUTIVE DIRECTOR,

TREASURER & NORTHEAST

COORDINATOR

Sue Heppenheimer
WESTERN REGION COORDINATOR

Jack Edwards, B.A., C.D.T., M.D.T., T.F.

MIDWEST & CANADA COORDINATOR

Milko Lamos, M.D.T.
SOUTHEASTERN COORDINATOR
Robert Jackson, M.D.T., T.F.

COMMITTEE CHAIRPERSONS

EDUCATION

Vincent V. Alleluia, M.D.T., T.F.

MEMBERSHIP

Max Toth

BOARD OF EXAMINERS

Charles Cottone, M.D.T.

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Print Last Name

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Print First Name                                               Middle Initial

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Print Address

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City                                               State                                       Zip Code + four

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Home Phone w/area code                                         Work Phone w/area code

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Fax w/area code                                                       Cell Phone/Beeper w/area code

Educational Profile: ___________________________________

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PRACTICAL EXPERIENCE:

Complete Dentures: ____ Yrs

Ceramics: ____ Yrs

Partial Dentures: ____ Yrs

Orthodontics: ____ Yrs

Crown & Bridge: ____ Yrs

Occlusion: ____ Yrs

Mandibular Physiology:  ____ Yrs

1)    Complete Application and attach a passport-size color photograph of yourself.

2)    Attach deposit in a $500.00 Check payable to  ASMDP (American Society of Master Dental Prosthologists) to this form.  New York City tuition is $6,500.00. The tuition for the other locations is $7,500.00.

3) Mail check and Form to designated address for the desired location.  You will be notified confirming your acceptance into that location.

4) Note:    $500.00 deposit is required to reserve your space in the class.  Registration is on
       a first come/first served basis and only with a deposit.

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