801-803-0005

Application

Please fill out the application below and we will be in touch soon!  Thank you for choosing Premier Dental Assisting School of Utah!

 

*First Name
*Last Name
*Address Street 1:
Address Street 2
*City:
*State:
*Zip Code
*Date of Birth
*Home Phone
Cell Phone
*Email
*High School
College:
Dates Attended:
Scrub Size (XS - XXL)
*Emergency contact name
*Relationship
*Address Street:
*Contact's City
*Contact's State:
*Contact's Zip:
*Contact's Phone:
Tell us about yourself! (Hobbies, interests, etc...)