*******To fill out Application for Radiation Safety Course Online: Submit this Form First then a link pops up to Proceed to Secure Payment Site******

<
 
(Address, City, State, Zip)
Phone
Name of Assistant(s) taking course

I affirm that the assistant listed above and taking the exam will receive "hands on" assistance from a qualified trainer, defined as a dental assistant with a radiology permit issued by the Wyoming State Board of Dental Examiners, a dentist or a dental hygienist licensed by the Wyoming State Board of Dental Examiners.

Signature (Dentist)

I understand that the exam will be mailed to me as soon as I return the DVD's. The DVD's may be kept for 10 working days. I understand that I may keep the workbooks for reference if desired. The applicant(s) will have two hours to complete the test and may not review the DVD's or workbooks during the test period. Upon successful completion of the exam, the WDA will mail the applicant(s) a certificate and a letter with further instructions on completing the process through the Wyoming Board of Dental Examiners.

Select Your Choice Below
Applicant #1, DVD's & Workbooks $50 (add $25 for each additional applicant)
$35 (add $10 for each additional applicant)
$35 (add $10 for each additional applicant)
$35 (add $10 for each additional applicant)
/No DVD's or Workbooks first 5 tests per year $10 each/$100 each after 5)