Greater New York Dental Meeting Program Guide 2009 - 3

Greater New York Dental Meeting Advanced Registration Form No Pre-Registration Fee 2 REGISTRATION CODE November 27 - December 2 1 PRIMARY REGISTRANT (Print or Type) One Form Is Necessary For Each Ofﬁce M.I. AUXILIARY PERSONNEL RH Hygienist HS Hygienist Student CA Assistant Certiﬁed No Fee No Fee No Fee ID School ID DANB Card GU CH DENTIST DN ADA Member UN Non-ADA Member ID International Dentist DR Resident GS Graduate Student DS Dental Student 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 Assistant No Fee Assistant Student No Fee Technician Certiﬁed No Fee Technician No Fee Technician Student No Fee Administrative Staff No Fee Non-Exhibiting $80 Dental Trade Guest/Spouse No Fee Children No Fee Credentials Needed ID School ID Business Card Business Card School ID Sponsor Business Card Sponsor Under 18 years First Name Last Name Complete Mailing Address State Zip Code/Postal Code ( Ofﬁce Home) City Country Fax Number First-time Registrant Registration Code Pre-Reg Fee Telephone Number Cancellation/Refunds Policy: Program ticket request for refunds must be in writing and postmarked no later than November 2, 2009. 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. Refunds will be mailed by February 2010. If you have paid by check for a course which has been sold out, you will automatically receive a refund by February 2010. Course # / Fee Course # / Fee Course # / Fee Course # / Fee Total E-mail ( I Do Not Wish To Receive Information Via E-mail) 3 ADDITIONAL REGISTRANT(S) Staff, Family, etc (Print or Type) M.I. Last Name First Name $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ $ /$ /$ /$ /$ $ Grand Total $ 4 PAYMENT METHOD Visa MasterCard American Express Expiration Date 5 MAIL REGISTRATION FORM TO: Check/Money Order Greater New York Dental Meeting Credit Card Number Name (As it appears on card) Signature (Indicates approval for charges to your account.) ADVANCED REGISTRATION DEADLINES Applications received after 11/1/09 will be processed but P.O. Box 4088 ~ Frederick, MD 21705-4088 not mailed and can be picked up on-site. On-line registraTelephone (301) 694-5243 tion will be accepted until 12/2/2009. If you register onFax (301) 694-5124 site, or after 11/26/09, a $30.00 administrative fee will be On-line Registration - WWW.GNYDM.COM assessed. No checks are accepted on-site. All credit card transactions are processed in If you fax your registration form U.S. dollars and are subject to the current exchange DO NOT ALSO MAIL IT. This will result in duplicate registration and charges. rates. Returned checks are subject to a $30.00 fee. 3

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Greater New York Dental Meeting Program Guide 2009

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