certification courses
Annual Meeting 2009
registration form

FILL OUT A FORM FOR ATTENDEE! GO TO THE BOTTOM OF THE FORM TO SUBMIT TO COMPLETE REGISTRATION.

REGISTRATION OPTIONS	COST
Dental Assistant Radiology Certification (two days, two luncheons, vendor exhibit area and Dentist of the Year Luau	$450
Dental Assistant Nitrous Monitoring Certification (one day course, one luncheon, vendor exhibit area and Dentist of the Year Luau	$175
CPR Recertification (American Heart Association two years for healthcare professional) To Ensure Class Being Held You Must Register 10 Days in Advance > of Course Date, Any Registrants on day of Course Will Be > Accepted on Space Available Basis	$40--must also be registered for the conference for at least one day

Please complete and submit the following information form.

Attendee 1: Name

First

M.I.

Last

Mailing Address

City

State

Zip Code

Daytime Phone Number

Cell Phone Number

E-Mail Address

Registration Category

Social Security Number

TN License Number

Date of License Registration