Get Student Trial Kit Sample Request Form

Completing the Student Trial Kit Sample Request Form online is an important step for practitioners participating in the ® Student Access Program. This guide will help you navigate through each section of the form efficiently and accurately.

Follow the steps to complete your request form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing your name in the designated field. Ensure that your full name is correctly spelled for identification purposes.
3. Select your professional title from the available options such as DDS or DMD. This designation is essential for verifying your eligibility.
4. Enter the name of your school in the appropriate section, as this is required to process your request.
5. Provide the complete school address, including street, city, state, and ZIP code, to ensure accurate delivery of the trial kit.
6. Insert your phone number in the designated field. This contact information is necessary for any follow-up regarding your request.
7. Indicate the number of Student Trial Kits you are requesting in the corresponding field.
8. Fill in your state dental license number. A copy of this license must be included with your submission to validate your request.
9. Sign the form in the designated signature area to confirm the accuracy of your information and your compliance with the program.
10. Enter the current date at the bottom of the form to timestamp your request.
11. After you have completed the form, review all entries for accuracy. Once verified, you can save your changes, download the form, print it, or share it as needed.

Complete your Student Trial Kit Sample Request Form online today to ensure you receive your sample promptly.