Greater New York Dental Meeting Program Guide 2016 - 10

Greater New York Dental MeeƟng
November 25 - November 30

Pre-RegistraƟon Form
1

PRIMARY REGISTRANT (Print or Type) One Form Is Necessary For Each Oĸce











First Name









Complete Mailing Address

( Oĸce











M.I.









 

  

Last Name



































Zip Code/Postal Code





















Fax Number







































 Check here if this is your Įrst Ɵme aƩending the

Country

Greater New York Dental MeeƟng
 Check here if member of AGD

E-mail
2



Telephone Number
State





Specialty

 Home)

City





RegistraƟon
Code

ADDITIONAL REGISTRANTΈSΉ Staī, Family, etc (Print or Type)

RegistraƟon
Code

Course # / Fee

Course # / Fee

Total

First Name






M.I.

Last
 Name 







________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________





















________

______/$______

______/$______

$___________

Grand Total $__________
3

REGISTRATION CODE

DENTIST
 ID InternaƟonal DenƟst
 RG Resident/Graduate Student
 DN ADA Member
 UN Non-ADA Member
 IDS InternaƟonal Dental Student
 IR InternaƟonal Resident
 DS Dental Student

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

CredenƟals
Needed
ID
Hospital ID
ID
ID
School ID
School ID
School ID

AUXILIARY PERSONNEL
 RH Hygienist
 HS Hygienist Student
 CA Assistant CerƟĮed
 DA Assistant
 AS Assistant Student
 CT Technician CerƟĮed
 DT Technician
 TS Technician Student
 ST AdministraƟve Staī
 NE Non-ExhibiƟng Dental Trade
 MD Medical Doctor
 RN Nurse
 ED Educator
 GU Guest/Spouse
 CH Children

No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
$95
No Fee
No Fee
No Fee
No Fee
No Fee

ID
School ID
DANB Card
ID
School ID
Business Card
Business Card
School ID
Sponsor
Business Card
ID
ID
School ID
Sponsor
Under 18 years

Sponsoring DenƟst's Name:

EXPERIENT IS THE ONLY
OFFICIAL HOUSING AGENCY
10

4

PAYMENT METHOD

 Cash/Money Order

 Visa

 MasterCard

Credit Card Number

 American Express
ExpiraƟon Date

Name (As it appears on card)
Signature (Indicates approval for charges to your account.)

CancellaƟon/Refunds Policy: Program Ɵcket request for refunds must be in wriƟng and
postmarked no later than November 7, 2016. Tickets/Badges must be included with
the cancellaƟon/refund request. Refunds requested aŌer this date will not be granted,
including requests based on absence due to illness, late arrival for courses, weather
and/or parking diĸculƟes. A $10.00 processing fee will be deducted from all refunds.
Refunds will be mailed by February 2017. If you have paid by check for a course which
has been sold out, you will automaƟcally receive a refund by February 2017.
5

MAIL OR FAX REGISTRATION FORM TO:

GREATER NEW YORK DENTAL MEETING
5202 Presidents Court - Room G100
Frederick, MD 21703
T: (844) 797-7469 (Toll Free DomesƟc)
T: (240) 439-2957 (InternaƟonal)
F: (301) 694-5124
On-line RegistraƟon - WWW.GNYDM.COM
If you fax your registraƟon form
DO NOT ALSO MAIL IT
This will result in duplicate
registraƟon and charges.

ADVANCED REGISTRATION DEADLINES
ApplicaƟons received aŌer 11/4/16 will
be processed but not mailed and can be
picked up on-site. On-line registraƟon will
be accepted unƟl 11/30/2016. If you register on-site, or aŌer 11/25/16, a $30.00
administraƟve fee will be assessed.
All credit card transacƟons are processed
in U.S. dollars and are subject to the current exchange rates.
RETURNED CHECKS ARE
SUBJECT TO A $30.00 FEE.
NO CHECKS ARE ACCEPTED ONͳSITE.
http://WWW.GNYDM.COM http://WWW.GNYDM.COM
Greater New York Dental Meeting Program Guide 2016

Table of Contents for the Digital Edition of Greater New York Dental Meeting Program Guide 2016
