Continuing Dental Education Registration Form

NOTE: Please register one person per form submission. To register multiple people, return to this page and submit a new form for each person.

This form is for paying by credit card only. If you want to pay by check or purchase order, you must go back to the Courses page and download the PDF, fill it out and mail it to us. We cannot accept an online registration for checks. Thank you.

Name:
Title:
(as it should appear on your tag...DR., MR., MRS., MS.)
Employer's Name:
(Staff registrants only)
Office Address:
City:
State:
Zipcode:
Office Phone:
Emergency Phone:
Email:
(Registration Confirmation will be sent via Email Only one week prior to the course)

Registration Categories (select one only)

DSDS/ADA Dentist
Non-DSDS/ADA Dentist
Dental Hygienist
Dental Assistant
Office Manager/Staff
Resident
Student
Spouse

REGISTRATION FEE:

DELAWARE “AGE ONE CONNECT THE DOTS” WORKSHOP
Thursday, January 8, 2015
6:00 PM to 9:00 PM
Sheraton Wilmington South, New Castle, DE
Of interest to Dentists and Staff
2 CE Credits … $50.00 registration includes dinner


TOTAL REGISTRATION $0

 
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