Greater New York Dental Meeting Program Guide 2012 - 10

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2 REGISTRATION CODE
DENTIST     DN UN IN RG No Fee No Fee Hospital ID School ID No Fee No Fee No Fee ID ID ID Fee Credentials Needed

Greater New York Dental Meeting
No Pre-Registration Fee

November 23 - November 28, 2012

Advanced Registration Form
ADA Member Non-ADA Member International Dentist Resident/Graduate Student  DS Dental Student

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M.I.
AUXILIARY PERSONNEL

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

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 RH Hygienist  HS Hygienist Student  CA Assistant Certiﬁed No Fee No Fee No Fee ID School ID DANB Card

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First Name

Last Name

       DA AS CT DT TS ST NE No Fee No Fee Assistant Assistant Student Technician Certiﬁed Technician Technician Student Administrative Staﬀ Non-Exhibiting Dental Trade  GU Guest/Spouse  CH Children

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

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Fax Number  First-time Registrant State

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Zip Code/Postal Code

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Registration Code Pre-Reg Fee Course # / Fee

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Complete Mailing Address

( Oﬃce

 Home)

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City

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Country

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E-mail

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( 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, 2012. 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.

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Specialty

Refunds will be mailed by February 2013. If you have paid by check for a course which has been sold out, you will automatically receive a refund by February 2013. Course # / Fee Course # / Fee Course # / Fee Total

3 ADDITIONAL REGISTRANT S Staﬀ, Family, etc (Print or Type)
Last Name

________ ________ ________ ________ ________ ________ ________ ________

$________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________ $________ ______/$______ ______/$______ ______/$______ ______/$______ $___________
Grand Total $___________

First Name                

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 MasterCard  American Express
Expiration Date

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5

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4 PAYMENT METHOD

Mail or Fax Registration Form To:

 Check/Money Order

 Visa

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 11/1/12 will be processed P.O. Box 4088 ~ Frederick, MD 21705-4088 but not mailed and can be picked up on-site. On-line Tel: (301) 694-5243 (Domestic & International) registration will be accepted until 11/28/2012. If Toll Free: (866) 229-2386 you register on-site, or after 11/24/12, a $30.00 adFax (301) 694-5124 ministrative fee will be assessed. On-line Registration - WWW.GNYDM.COM NO CHECKS ARE ACCEPTED ON SITE. If you fax your registration form All credit card transactions are processed in DO NOT ALSO MAIL IT. U.S. dollars and are subject to the current exchange This will result in duplicate rates. Returned checks are subject to a $30.00 fee. registration and charges.
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Greater New York Dental Meeting Program Guide 2012

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