CERTIFICATION OF BOARD APPROVED REGISTERED DENTAL ASSISTING PROGRAM COMPLETION
Applicant Name:
SSN/FEIN/ITIN:
To qualify by completion of a board-approved educational program in registered dental assisting, complete Sections I and
II of this page, or attach a copy of your diploma/certificate of program completion from the institution to the application.
Section I:
Name of Educational Institution:
School Street Address:
City/Zip:
Name of Dean or Program Director:
Name of Educational Program*:
Section II:
I hereby declare, under penalty of perjury under the laws of the State of California, that I have
personally reviewed the educational institution’s records and can verify that the applicant enrolled in
the above-named registered dental assisting program* on the _____day of ____________, 20______.
The student Has Graduated, or is Expected to Graduate* from the above-named
Board-approved RDA program, with a certificate of completion in Dental Assisting on the _____day of
____________, 20______.
*The Dean, Program Director, or Authorized Official must certify actual graduation. I understand that, in the event the
expected date of graduation as indicated above is after the date on which this application is filed, I must certify, in writing to
the Dental Board, confirmation of graduation no later than 30 days prior to examination or the applicant will not be allowed
to take the exams and will have to re-apply as a first-time applicant during a later exam cycle. I understand all certifications
and institutional documents must contain original signatures and be submitted with this application.
I hereby declare that the foregoing statements provided by me in Sections I and II above are true and correct.
CERTIFYING SIGNATURE OF DEAN OR AUTHORIZED OFFICIAL DATE SIGNED
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