Registration

Full Name*

Business Name

Street Address*

Address (Cont.)

City*

State / Province*

Zip / Postal Code*

Country*

Primary Phone Number*

Secondary Phone Number

Fax

Email*

Emergency Contact Name*

Emergency Contact Phone Number*

Date Of Birth (mmddyyyy)

Select Preferred Course*

Do you want to attend the anatomy course (required
to certify)*

Gender (M or F)*

Allergies or Medical Problems (in case of
emergency)*

Reason(s) for attending this course.*

Number of years working with horses and types of
horses*

Previous formal education and training*

Horse handling experience, courses, schools, etc*

Two or more Professional references are required,
one of which should be a Two or more Professional
references are required, one of which should be a
veterinarian with whom you are affiliated,
including address and phone*

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After submitting this form, you may call the office at 208-366-2315 with your credit card information.

The application is also available in two additional formats:

.doc Form
.pdf Form

1.Download the application form
2.Print and complete the form
3.Sign and Date
4.Enclose Deposit
5.Mail to: The Academy Of Equine Dentistry, P.O Box 999, Glenns Ferry, ID, 83623

If you do not have either Microsoft Word or Adobe Acrobat, call 1-208-366-2315 and we will fax the application to you.