Payment
  Pre-pay* Door
Dentists (member) $79.00 $89.00
Dentists (non-member) $89.00 $99.00
Hygienist/R.D.A. (member) $59.00 $69.00
Hygienist/R.D.A. (non-member) $69.00 $79.00
* The "pre-pay" rate constitutes a payment made at least 8 days prior to the date of the seminar.

Required fields are marked (*)
   
Seminar
Title
First Name *
Last Name *
Name on Credit Card  *
registering for yourself or other?  *
(If other, please specify name.)
 


Address *
City *
State *
Zip *
Phone * e.g. (999-999-9999)
Fax  
e.g. (999-999-9999)
Email *
Lic. No. *
  If you don't have a license number type 00000
            

 
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