Greater New York Dental Meeting Program Guide 2010 - 3

Greater New York Dental Meeting
No Pre-Registration Fee

2 registratiOn COde

®

November 26 - December 1

Advanced Registration Form

	
M.I. Last Name m Home)

1 Primary registrant (Print or type) One Form is necessary For each Office

First Name

	
	 	
	 		

	
	 	 		
No Fee No Fee No Fee ID School ID DANB Card

	
		
auxiliary PersOnnel m RH Hygienist m HS Hygienist Student m CA Assistant Certified

	

	

	

	

	

	

	

		

dentist m DN ADA Member m UN Non-ADA Member m IN International Dentist m DR Resident m GS Graduate Student m DS Dental Student m m m m m m m No Fee No Fee DA AS CT DT TS ST NE

Fee No Fee No Fee No Fee No Fee No Fee No Fee

Credentials needed ID ID ID Hospital ID School ID School ID Fee No Fee No Fee No Fee No Fee No Fee No Fee $80

Credentials needed ID School ID Business Card Business Card School ID Sponsor Business Card Sponsor Under 18 years

	 	
	 	
Fax Number m First-time Registrant State

Complete Mailing Address

	 	
	
Zip Code/Postal Code

	 	
	 	

	 	 	 	
	
Registration Code Pre-Reg Fee Course # / Fee

(m Office

	

	

	

	

	

Assistant Assistant Student Technician Certified Technician Technician Student Administrative Staff Non-Exhibiting Dental Trade m GU Guest/Spouse m CH Children

	 	 	
	 	 	 		

City

	 	 	 	 	 	 	 	 	 		 		

	

	

	

	

Country

	

	

	

	

	 	 	 Telephone Number 	 	 	
	 	

E-mail

	

	

(m I Do Not Wish To Receive Information Via E-mail)

	 	

	 	

Cancellation/refunds Policy: Program ticket request for refunds must be in writing and postmarked no later than November 8, 2010. Tickets/Badges must be included with the cancellation/refund request. Refunds requested after this date will not be granted, including requests based on absence due to illness, late arrival for courses, weather and/or parking difficulties. A $10.00 processing fee will be deducted from all refunds.

	

	

	

Specialty

refunds will be mailed by February 2011. If you have paid by check for a course which has been sold out, you will automatically receive a refund by February 2011. Course # / Fee Course # / Fee Course # / Fee Total

3 additiOnal registrant(s) staff, Family, etc (Print or type)
________ ________ ________ ________ ________ ________ ________ ________

First Name

$________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________
grand total $___________

	 	 	 	 	 	 	 	
m MasterCard m American Express
Expiration Date

	 	 	 	 	 	 	 	
5

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 M.I. 	 	 	 	 	 	 	

Last 	 Name	 	 	 	 	 	 	 	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

	 	 	 	 	 	 	 	

		 		 		 		 		 		 		 		

4 Payment methOd

mail registratiOn FOrm tO:

m Check/Money Order

m Visa

greater new york dental meeting

Credit Card Number

P.O. Box 4088 ~ Frederick, MD 21705-4088 Telephone (301) 694-5243 Fax (301) 694-5124 On-line Registration - www.gnydm.COm

advanCed registratiOn deadlines Applications received after 11/1/10 will be processed but not mailed and can be picked up onsite. On-line registration will be accepted until 12/1/2010. If you register on-site, or after 11/26/10, a $30.00 administrative fee will be assessed.

Name (As it appears on card)

nO CheCks are aCCePted On-site.
if you fax your registration form dO nOt alsO mail it. this will result in duplicate registration and charges.

Signature (Indicates approval for charges to your account.)

All credit card transactions are processed in U.S. dollars and are subject to the current exchange rates. Returned checks are subject to a $30.00 fee.

3
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Greater New York Dental Meeting Program Guide 2010

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