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AGD Mastertrack: A La Carte Application

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Phone

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Name

First Last

Cell Phone Number

State(s) of Licensure

Dental License Number

AGD Number

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Office Address

Street Address City State / Province / Region ZIP / Postal Code Country

Please Describe Your Current Practice

Solo or Group

Number of Associates

Number of Staff

This program has been approved for tuition payment under the Post-911 GI bill –

For Post 9/11 GI Bill® (Ch 33) students and VA Vocational Rehabilitation and Employment (Ch 31) students, our tuition policy complies with 38 USC 3679(e) which means Post 9/11 and Vocational Rehabilitation and Employment students will not be charged or otherwise penalized due to a delay in VA tuition and fee payments. For eligibility consideration, a Post 9/11 GI Bill student must submit a VA Certificate of Eligibility (COE) and a Vocational Rehabilitation Student must provide a VAF 28-1905 form. [Please list all additional requirements your school will ask a student to satisfy which are permitted under 38 USC 3679(e)] Please see 38 USC 3679(e) for complete details.

GI Bill® is a registered trademark of the U.S. Department of Veterans Affairs (VA). More information about education benefits offered by VA is available at the official U.S. government website at www.benefits.va.gov/gibill

AGD Mastertrack: A La Carte Application

Refer to your AGD transcript for remaining participation hours.