GNYDM2023 - 14
Greater New York Dental Meeting
November 24 - November 29
Pre-Registration Form
1
PRIMARY REGISTRANT (Print or Type) One Form Is Necessary For Each Office
First Name
Complete Mailing Address
City
Country
E-mail
m Check here if this is your first time attending the Greater New York Dental Meeting
2 ADDITIONAL REGISTRANT(S) Staff, Family, etc (Print or Type)
First Name
M.I.
Last Name
_______
_______
_______
_______
_______
_______
_______
_______
3 REGISTRATION CODE
Fee
m DN U.S. ADA Member
m UN U.S. Non-ADA Member
m RG Resident/Graduate Student
m DS Dental Student
m ID International Dentist
m IR
m IS
m RH Hygienist
m HS Hygienist Student
m CA Assistant Certified
m DA Assistant
m AS Assistant Student
m CT Technician Certified
m DT Technician
m TS Technician Student
m ST Administrative Staff
m NE Non-Exhibiting Dental Trade
m MD Medical Doctor
m RN Nurse
m NS Nursing Student
m PS Pre-Dental Student
m TH Dental Therapist
m ED Educator
International Resident
International Dental Student
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
$135.00
No Fee
m PH Non Dental Healthcare Worker No Fee
m PM Non Medical Physician
No Fee
No Fee
No Fee
No Fee
No Fee
No Fee
Credentials
Needed
ID
ID
Hospital ID
School ID
ID
School ID
School ID
ID
School ID
DANB Card
ID
School ID
Business Card
Business Card
School ID
Sponsor
Business Card
ID
ID
ID
ID
ID
ID
ID
ID
Name (As it appears on card)
Signature (Indicates approval for charges to your account.)
Cancellation/Refunds Policy: Program ticket request for refunds must be in writing and
postmarked no later than November 8, 2023. 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 $20.00 processing fee will be deducted from all refunds.
Refunds will be mailed by February 2024. If you have paid by check for a course which
has been sold out, you will automatically receive a refund by January 2024.
5 MAIL OR FAX REGISTRATION FORM
ALONG WITH PAYMENT TO:
GREATER NEW YORK DENTAL MEETING
E-mail: victoria@gnydm.com
On-line Registration - WWW.GNYDM.COM
If you fax your registration form
DO NOT ALSO MAIL IT
This will result in duplicate
registration and charges.
ADVANCED REGISTRATION DEADLINES
Registrations received after 11/15/23 will
be processed but not mailed and can be
picked up on-site. On-line registration will
be accepted until 11/29/2023. If you register
on-site, or after 11/24/23, a $50.00
administrative fee will be assessed.
All credit card transactions are processed
in U.S. dollars and are subject to the current
exchange rates.
RETURNED CHECKS ARE
SUBJECT TO A $50.00 FEE.
12
NO CHECKS ARE ACCEPTED ON-SITE.
4
Registration
Code
M.I.
(m Office m Home)
State
Zip Code/Postal Code
Last Name
Registration
Code
m Check here if member of AGD
Specialty
Telephone Number
Fax Number
*EMERGENCY CONTACT*
Name
Telephone Number
SCAN QR CODE TO
REGISTER ONLINE AND
BOOK YOUR COURSES
Course # / Fee
_______/$_______
_______/$_______
_______/$_______
_______/$_______
_______/$_______
_______/$_______
_______/$_______
_______/$_______
Total
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Grand Total $__________
PAYMENT METHOD
m Cash/Money Order m Visa m MasterCard m American Express
Credit Card Number
Expiration Date
http://WWW.GNYDM.COM
GNYDM2023
Table of Contents for the Digital Edition of GNYDM2023
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