CE Request Form

I would like to request continuing education credits for a CDA correspondence class. I have reviewed the material and attached my summary.

Please complete the following information

 

Name: _____________________________
License: ____________________________
ADA# (if applicable): __________________

Mailing Address: ________________________________
City: __________________________________
State/Province: __________________________
Zip/Postal Code: ___________________

Phone: ________________________
Fax: __________________________
Email: _________________________

 

______________________________________________________________
Signature:                                                                        Date

 

*****Mail this form along with your course summary to the following address:

                                    California Dental Association
                                    Attn: Continuing Education
                                    1201 K Street Mall
                                    Sacramento, CA  95814