Enrollment Application Personal InformationName* First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Date of Birth Date Format: MM slash DD slash YYYY EducationGraduated From High School or GED Certificate?* Yes No If yes, when did you graduate? Date Format: MM slash DD slash YYYY Name of schoolCityName As It Appears on High School Records First Middle Last Maiden Do you have a copy of your High School Diploma or GED Certificate?* Yes No Have you pursued education after High School?* Yes No If yes, where?How did you hear about us?FriendWeb SearchNewspaperMethod of PaymentI have selected the following payment plan (see note below about deposit to assure place in next class)* Option 1: $2975 on or before the first day of class ($500 deposit to reserve class) Option 2: $900 deposit, $275 before each class (8 payments), total tuition $3100 Option 3: $800 deposit, $300 before each class (8 payments), total tuition $3200 All information stated above is true and correct:* Yes, I agree.Note: A minimum deposit of $500 is required to guarantee your place in the next class. Class space is limited to the first twenty students accepted. Any applicant who is not accepted by Austin Dental Careers will receive a complete refund of any deposit or payments.Print Name First Last Signature
