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Last four of SSN and Date of Birth will be kept confidential and will only be released to state regulatory bodies and as required by law.

Date of Birth (mm/dd/yyyy)

Last 4 of Social Security Number

If you are an Academy of General Dentistry member, please list your AGD Number for CE credit reporting purposes:

To better serve and understand our dental assisting community, we are hoping to learn more about our test takers, certificants, and learners through the collection of voluntarily disclosed demographic information. The next 3 questions are optional, but your responses will help to improve our ability to better serve our stakeholders.

Gender Identity: (select one)

Primary Language (select one):

Race/Ethnicity: (select all that apply)
- American Indian, Alaska Native, or Indigenous
- Asian
- Black or African American
- Hispanic, Latino, or Spanish
- Middle Eastern or North African
- Native Hawaiian or Other Pacific Islander
- White
- Other race or ethnicity:
- Unknown/Prefer not to answer

If you work in a state different than the one in which you live, indicate your work state below:

If you work in a dental office, indicate the type(s) of radiography used:
- Film
- Digital

Attestations

To proceed, you must agree to the following:

I agree that this account is for my use only.*
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I agree that I will not share my login or password with anyone.*
- Agree

I agree that I will not copy any exam or product content or use the exam or product content to create my own review product or study set.*
- Agree

I agree that I will not broadcast or share any DANB exam or DALE Foundation product content with other individuals or organizations.*
- Agree

I agree to comply with all DANB or DALE Foundation policies and procedures and all applicable state and federal laws, rules, and regulations.*
- Agree

I agree and understand that DANB may release my personal information including, but not limited to, exam application status and, exam results, and pass/fail status, to employers, educators, regulators, government agencies, and any individual or organization that has paid for my exam or application fees, in accordance with DANB’s Privacy Policy, and/or legal obligations.*
- Agree

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Suite 900 Chicago, IL 60611

Representatives are available M-F,

8:00 a.m. to 4:30 p.m CT.

email@dalefoundation.org
877-510-3253

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