| Please print and fill out this form then fax to: 616.454.8067, or, mail to: International Dental Seminars, 1361 Union N.E., Grand Rapids, MI 49505. If you have questions with this form please call us at: 616.454.8388 / 800.524-2317
Name:_____________________________ CDT DDS RG Address:_________________________________________________ City/State/Province/Zip code:_________________________________ Phone: ( )_______________ Fax: ( )_______________ E-mail :_____________________@____________________________ THE COURSE I AM SIGNING UP FOR IS: (please check one)
DATE OF COURSE:___________/___________/ ________ COURSE CITY: ___________________________________ **NOTE: REGISTRATIONS MUST BE RECEIVED 2 WEEKS PRIOR TO ALL COURSES** CHECK (made payable to Russell T. DeVreugd C.D.T.)
Account Number:_____________________________________Expiration Date:______ CVV2 number (3 or 4 digit number on BACK of credit card): ______________________ Print Name as it Appears on Card: ___________________________________________ SIGNATURE:___________________________________________________________ Cancellation Policy: Full refund less $100.00 USD processing fee if cancelled 30 days prior to seminar date. Within 30 days, no refund will be given. However, payments can be transferred (one time only) to another seminar of the SAME NAME HELD WITHIN THE SAME CALENDAR YEAR. |
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"A Practical Approach to Posterior Tooth Morphology": COMPLETE 2 DAY COURSE $1,025.00 USD (14 NBC Credit hours 2 days)