Greater New York Dental Meeting Guide 2018 - 10

Greater New York Dental Meeting
November 23 - November 28

Pre-Registration Form
1

Primary Registrant (Print or Type) One Form Is Necessary For Each Office

	

	

	

	

	

First Name			

	

	

	

	

Complete Mailing Address 	

(m Office

	

	

	

	

	

	

	

	

	

	

	 	

Specialty

	

	

	

	

	

	

	

	
State

	

	

Zip Code/Postal Code				

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	

	
	

	

	

	

  

	

	

	

  

	

	

	M.I.

	

	

	

	

	

	

	

	

	

	

	

	

	

  

	

Fax Number

m Check here if this is your first time attending the

Registration
Code

Additional Registrant(s) Staff, Family, etc (Print or Type)

	First Name	

	

Greater New York Dental Meeting
m Check here if member of AGD

E-mail
2

	

		

Country

	

	    	

Last Name						

m Home)							Telephone Number

City					

	

	

M.I. 	

Registration
Code

Course # / Fee

Course # / Fee

Total

	Last Name 	

	

	

  m__________
CEPASSOPTION

BUNDLE
495.00 _______/$_______
_______/$_______

$_________

	

	

	

	

	

CEPASSUNL
  m__________

BUNDLE
795.00 _______/$_______
_______/$_______

$_________

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

	

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

	

	

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

	

	

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

	

	

	

	

	

	

	

	

   __________

_______/$_______ _______/$_______

$_________

	

Grand Total $__________
3

4 Payment Method	

Registration code

					
dentist	 	
Fee	
m	 DN	 U.S. ADA Member	
No Fee	
m	 UN	 U.S. Non-ADA Member	
No Fee	
m	 RG	 Resident/Graduate Student	 No Fee	
m	 DS	 Dental Student	
No Fee	
m	 ID	 International Dentist 	
No Fee	
m	 IR	 International Resident	
No Fee	
m	 IS	 International Dental Student	 No Fee	

Credentials
Needed
ID
ID
Hospital ID
School ID
ID
School ID
School ID

Auxiliary Personnel
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	 PH	 Physician	
m	 RN	 Nurse	
m	 NS	 Nursing Student	
m	 PS	 Pre-Dental Student	
m	 TH	 Dental Therapist	
m	 GU	 Guest/Spouse	
m	 CH	 Children	
m	 ED	 Educator	

ID
School ID
DANB Card
ID
School ID
Business Card
Business Card
School ID
Sponsor
Business Card
ID
ID
ID
ID
ID
ID
Sponsor
Under 18 years
ID

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	
No Fee	
No Fee	
No Fee	
No Fee	

m Cash/Money Order m Visa
m MasterCard
							
Credit Card Number						

m American Express
		
Expiration Date

									
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 3, 2018. 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 2019. If you have paid by check for a course which
has been sold out, you will automatically receive a refund by February 2019.
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 Domestic)
T: (240) 439-2957 (International)
F: (301) 694-5124
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 11/2/18 will
be processed but not mailed and can be
picked up on-site. On-line registration will
be accepted until 11/28/2018. If you register on-site, or after 11/23/18, a $30.00
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 $30.00 FEE.
No checks are accepted on-site.
http://WWW.GNYDM.COM
Greater New York Dental Meeting Guide 2018

Table of Contents for the Digital Edition of Greater New York Dental Meeting Guide 2018
