A requirement for renewal of Dental License by
CA. DENTAL BOARD

by Att. Shab David Kerendian on Jan 18th, 2004 (Sunday)

9.00 am till 1.00 pm
(AGD & CA Board approved 4hrs C.E. units ) at

Diamond palace cuisine of india
1241 GRAND AVE SUITE # L , DIAMOND BAR CA
909-860-2625

(Please print in capital letters or attach your business card)

Name Dr/RDH/RDA/DA _______________________
_________________________ Lic. no _________
Circle one first middle initial Last

Address _

City State Zip

Phone no fax no

Are your a PDS member Yes No ARE Membership no

Registration Fee (llunch Included)

Before Jan 11th , 2004 After Jan 12th , 2004 Dentist

Non Members $ 59.00 $ 69.00

Members $ 49.00 $ 59.00

Hygienist / R.D.A

Non Members $ 49.00 $ 59.00

Members $ 39.00 $ 49.00

For Registration / Membership / Staff Discount Over the phone please call

TOLL FREE 1-866-422-5573 (1-866-4-CALL-PDS) OR 909-933-9076

We accept Visa, Master card, American Express &Discover

Visit our on website www.pdsociety.com to download Membership Form

Make check payable to
PDS
1361, E. 4th Street,
Ontario CA. 91764