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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

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

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