DANB Indiana State Booklet Order Form


Published on

Application for Indiana State Booklet order form.

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

DANB Indiana State Booklet Order Form

  1. 1. Questions? 1-800-367-3262 • www.danb.org The Dental Assisting National Board, Inc. (DANB) 2011 State PublicationsDANB’s state publications are a complete guide to national dental assisting regulatory requirements.DANB exams are recognized or required in 38 states, the District of Columbia, the U.S. Air Force and the U.S. Department of Veterans Affairs. DANB’s 2011 State Career Ladder Templates for Dental Assistants is a reader-friendly guide outlining dental assistant requirements and career opportunities for dental assistants in all 50 states. DANB’s 2011 State Fact Booklet provides current state requirements and excerpts from State Practice Acts re- lated to dental assisting. It also features State Board of Dentistry contact information, accepted/required DANB exams, the number of DANB Certificants in each state, a list of CODA-accredited programs and comparative salary information. Unit Cost (circle one) Quantity TOTAL Certificant ProfessionalDANB’s 2011 State Career Ladder $40 $65 (3480-11) _________ $_________Templates for Dental Assistants (3480-10)DANB’s 2011 State Fact Booklet $40 $65 (3440-10) (3440-12) _________ $_________State Guide Pack *special rate*: DANB’s 2011 StateCareer Ladder Templates for Dental Assistants and $60 $100 _________ $_________DANB’s 2011 State Fact Booklet Overnight shipping is available for $20. For overnight shipments of more than 10 books or for an international delivery request, please call 1-800-367-3262. Orders for overnight shipping must be received by DANB no later than 2 p.m. CST. Overnight shipping fee $_________Shipping (U.S. standard rate) and handling are included in the cost. Please allow 3-4 weeks for shipping. ORDER TOTAL $_________Please print clearly.Name (print or type)_____________________________________________________________ SSN*_________________________________________Organization Name (only if sending to work address) ________________________________________________________________________________Address (no P.O. Box numbers)_______________________________________City____________________State__________Zip___________________Daytime Phone Number (_____)_________________________________ E-mail _________________________________________________________DANB Certification Number ___ ___ ___ ___ ___ ___ *Social Security Number assists DANB in properly processing the candidate’s order.MDANB no longer accepts purchase orders or personal checks for publication orders.Please indicate payment information below. Cashier’s Check/Money Order payable to the Dental Assisting National Board, Inc. or DANB All DANB publication fees VISA MASTERCARD DISCOVER AMERICAN EXPRESS are nonrefundable.Credit Card Authorization: Allows DANB to charge your credit card account. Please complete all information.Name (print or type)____________________________________________________ SSN*___________________________________________________Credit Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date __ __/__ __ Amount $_________________________Cardholder’s Name______________________________________________Cardholder’s Signature___________________________________________Cardholder’s Billing Address_____________________________________________________________________________________________________City/State/Zip_____________________________________________________________Phone Number (_______)________________________________By signing, the cardholder acknowledges purchase of the aforementioned DANB publications in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholder’sagreement with the issuer. Furthermore, the cardholder understands that the signature obtained on this form shall be used to indicate receipt of purchase. All DANB publication fees are nonrefundable. FAX to: or MAIL to: 312- 642-8507 Dental Assisting National Board, Inc. DANB Publications 444 N. Michigan Ave., Suite 900 Chicago, IL 60611-3985