Mastering Dental Implants PHP Form

First Name	*
Last Name	*
Email	*
Address	*
City	*
State	*
Zip	*
AGD # (if applicable)
Card Type	*
Name on Card	*
Card Number	*
Expiration Date (MM-YYYY)	*
Security Code	*
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Course Dates	*	September 7-8, 2007 November 2-3, 2007
Your Message
ATTENDANCE IS LIMITED, SO BE SURE TO REGISTER EARLY The registration fee ($2,365.00) includes course materials, continental breakfast, lunch and 15 hours of CE credit. You may register by phone, fax, or mail. Implant Dentistry Today 39 Hickory Hills Circle Little Rock, AR 72212 Phone: 800-383-7048 Fax: 501-224-1990 Cancellation Policy: If cancellation or change in course date is necessary, the registration fee will be refunded up to seven days prior to the course; however, a $165.00 processing fee will be charged. If cancellation occurs during the week prior to the course, the registration fee will not be refunded but may be applied towards a future course date.