application Form – Commission on Ohio Dental Assistant Certification

Address:

City:

State

Zip:

Phone (Home):

Phone (Office):

Are you currently enrolled in a Dental Assisting program? Yes No

The exam is scheduled on a Saturday or Sunday in the fall and spring each year. Please check the exam you are applying for, you will be notified 30 to 60 days before the exam of the date for which you are scheduled.

Spring (date to be determined) January prior to exam

Fall (date to be determined) June prior to exam

Full Exam: The full exam consists of three parts, Clinical, Written and Radiology*. You must pass each part of the exam to achieve Ohio Certification. *Holding a current Radiology Certificate does not exempt applicant from taking and passing the radiology portion of the exam.

Retake: (check all that apply):

Written

Clinical

Radiology

Date(s) exam previously taken:

Examples of additional education for retake:

Last name at time of previous exam:

Persons with disabilities needing assistants are asked to notify the Commission at the time of application. Attach letter listing reason for request and type of assistance needed. Please be specific regarding the type of assistance needed:

1. PROOF OF CURRENT CPR CERTIFICATION (MUST BE CURRENT AT TIME OF EXAM)

A. EMPLOYER NOTARIZED RECOMMENDATION

B. SCHOOL LIST: NOTARIZED INSTRUCTOR RECOMMENDATION
(Use for recent graduates or students currently enrolled in the final year of a Dental Assisting Program)

3. FEE Check or Money Order payable to Commission Ohio Dental Assistant Certification or CODA

Schools using a Purchase Order must include a copy of the PO with applications.

$65.00 Full Exam

$25.00 Retake one part

APPLICATIONS WILL NOT BE PROCESSED UNTIL ALL ITEMS ARE RECEIVED

Mail Application and payment to: Commission on Ohio Dental Assistant Certification
1501 Centerview Drive
Copley, Ohio 44321
Attach copy of CPR here

COMMISSION OHIO DENTAL ASSISTANT CERTIFICATION Examination Application