Please enable JavaScript in your browser to complete this form.Participants will be required to place at least 6 Pit and Fissure Sealants under the observance of their supervising Dentist. Upon successful completion of the lecture, clinical instruction, and return of verification of sealant placement form, participants will receive a certificate to perform Pit & Fissure Sealants. Name of Dental AssistantEmployer Dentist(s):Name *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutNumber of SealentsNumbersNumbers Numbers Numbers Numbers (copy)Numbers (copy) (copy)Patients initialsName *Name *Name *Name *Name *Name *DateDate Date Date Date Date Date Doctors Signature *Clear SignatureSubmit