| Name of
Technician__________________________________________________________________ |
| Telephone
(
)___________________________ Fax
(
)____________________________ |
| Address
__________________________________________________________________________ |
|
__________________________________________________________________________ |
| Town
__________________________ County ____________________ Zip
__________________ |
|
| Do you hold CDT, MDT or other
Certification: YES________ NO________ |
| Please indicate type of
certification, and in which areas you are
certified________________________ |
| __________________________________________________________________________________ |
| Number of years you have been a
dental technician _________ |
| What are your areas of
specialization?___________________________________________________ |
| __________________________________________________________________________________ |
| Name and address of Laboratory
where you are employed___________________________ |
| __________________________________________________________________________________ |
| __________________________________________________________________________________ |
|
| Signature of applicant___________________________________________________ |
|
|
| Annual
Technician Dues are $20.00 per Technician and should be sent with
application. Make checks payable to LIDLA. |
|
