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

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

PRESIDENT

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

VICE PRESIDENT

Angelo Calcagno, MDT

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.

 

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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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E-mail

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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)    For the onsite at NYU course, attach deposit of $500.00 check payable to  ASMDP (American Society of Master Dental Prosthologists) to this form.  The tuition is $7,500.00.
For the home study course, attach tuition of $7,500.00 check payable to DPDC (Dental Prosthologist Development Corporation) to this form. 

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
. Once your space in the class is reserved, this deposit is non-refundable.

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

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