Wyoming Dental Association and Safety Certification
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Dental Assistant’s Radiology Course Access (choose one)
Wyoming/ADA Members Free Access
Access and Payment for Non-Members
Dental Assistant’s Radiology Course
ADA Number
ADA Member
Participant’s First Name
*
Participant’s Last Name
*
*
The name entered here, will be the name printed on the certificate
Dental Assistant’s Radiology Course Payment Information
Participant’s First Name
*
Participant’s Last Name
*
Name as it appears on Credit Card
*
Email
*
Billing Address
*
City
*
State
*
Country
*
ZIP
*
Credit Card Number
*
Expiration Date
*
Card Code
*
Amount
$
