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More Information

Questions?
Call Tiffany at
919-878-2077 or
toll-free 877-871-6002
t.johnson_sunrisedental@yahoo.com

Academic Officer:
Paulette Jolly
919-878-2077
1009 Spring Forest Rd.
Raleigh, NC 27615

Owners:
Dr. Dinah Vice & Rick Vice

Ready?
Download our application.

Home of Sunrise School Of Dental Assisting

Student Application Form

Date:
Name:		Maiden Name
Social Security #		Date of Birth
Current Address		City
State		Zip Code
Home #		Work #
Cell #		High School
High School Address		City
State		Zip
High School Graduate?		Year of Grad?
GED?	YES NO	Have you attended a College or Technical Institution?
Graduated?	YES NO	4 or 2 Year Degree?
Name of College		College Address
Date of Graduation		How I first heard about this program:

In case of emergency contact:
Name		Phone #
Relationship		Address
City		State
Zip
I wish to be considered for acceptance to the following program:
	Saturday Classes Tuesday and Thursday classes
Location:
North Carolina	Raleigh Greensboro Fayetteville Asheville	South Carolina	North Charleston Greenville Columbia Florence
Please submit a short one to two page essay on why you would like to be a Dental Assistant and why you feel you would be an asset to the field.

I understand that there is a $25 nonrefundable application fee to be included with my application.
Please mail or bring your application fee and document of graduation to: Sunrise School of Dental Assisting 1009 Spring Forest Rd. Raleigh, NC 27615 Attention Paulette Jolly, School of Dental Assisting

Career Assessment Questionnaire

First Name:

MI:

Last:

Current Address:

City:

State:

Zip Code:

DOB:

DL #:

Phone #[Day]:

Evening #:

Cell #:

Marital Status:

Married Single Divorced Other Dependants

Are you a U.S. Citizen?:

Have you ever worked in health care?:

Have you ever been convicted of a felony?:

EDUCATION
What high school did you attend?
Do you have a diploma?
What year did you graduate?
Do you have college experience?
Do you have any vocational training?
EMPLOYMENT INFORMATION
Do you currently have a job?
If so, how will your job schedule affect your schooling?
If you don' t have a job, will you need to work at any time while you attend school??
and if so, how will this impact your schooling?
Once you have started your training, are you willing & able to make a serious commitment?

Please rate yourself	Excellent	Good	Fair	Poor
Attitude
Honesty
Initiative
Creativity
Enthusiasm
Cooperation
Punctuality
Attendance
Dependability
Technical Skills
Communication Skills
Working Relations
Work Ethics

Do you have any physical or educational challenges? (for example color blindness or dyslexia)criminal convictions: Important Notice to Student Applicants: Students must be aware that certain employment opportunities in the health care industry are not open to individuals with certain type of convictions. A criminal background check will be performed.

In connection with my application with Sunrise School of Dental Assisting, I understand that a consumer report, which may contain public records information, is being requested.

Applicant's Signature:

Date signed: