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

 Application Form for the onsite MASTER COURSE
in the Western Region
for Continuing Education Courses  ASMDT Program.

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.

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

_(_____)______________________(_____)________________

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

_(_____)______________________(_____)________________

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 two passport-size (2x2) color photographs of yourself.

2)    Attach deposit in a $500.00 Check payable to  ASMDT (American Society of Master Dental Technologists) to this form.  The tuition for the Western Region is $7,500.00.

3)    Mail check and Form to the home address at the top of this form.  You will be notified confirming your acceptance.

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.
Please note: You are purchasing knowledge and information. Therefore, there are no refunds.

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