To Enroll by Phone: Call (859) 323-8155 or 8187

Course Registration Form
**Please note that this online form may not be a secure transmission.  If you do not wish to register online, you may go to a printable version of the form by clicking here and mail or fax it to us.**

Last Name    First Name    Degree

Street Address
                           
                 City    State  KENTUCKY ALASKA ALABAMA ARKANSAS AMERICA SAMOA ARIZONA CALIFORNIA COLORADO CONNECTICUT CANAL ZONE DIST. OF COLUMBIA DELAWARE FLORIDA GEORGIA GUAM HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS LOUISIANA MASSACHUSETTS MARYLAND MAINE MARSHALL ISLANDS MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO PALAU RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA US VIRGIN ISLANDS VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING     Zip

Office Phone      Home Phone      Fax No.

Last 4 digits of Social Security #       E-Mail Address 

Please choose:  General Dentistry Endodontics Oral Pathology Oral and Maxillofacial Surgery Orthodontics Pediatric Dentistry Periodontics Prosthodontics Radiology TMJ / TMD Assistant Hygienist Office Staff    UKCD Alumni: Yes    Class of
                                                                                                        No