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Advanced Training for Predictable & Profitable Mini Implant Success “Mastering Mini Dental Implants” DoubleTree Guest Suites Anaheim, California March 13th-14th, 2009 June 12th-13th, 2009 October 2nd-3rd, 2009 Interested in expanding your practice by adding MDI? Please fax this form to Registration Form Mini Dental Implant Training Course Tuition: $1,395.00 Dentist Tuition: $695.00 Staff 714-838-1213 Select one: First Name ________________________ Middle Initial ______ Last Name ______________________________ DDS / DMD Office Address _____________________________ City ______________________ Sate _______ Zip Code ____________ Office Phone # _______________________________________ Office Fax # _______________________________________ E-mail Address _______________________________________ Date(s) you wish to attend ____________________________ ______________________________________________________________________________________________________ Credit Card/Payment Information Card Holder’s Name _________________________________________________________________ Select Payment Option: MASTERCARD Am. EXPRESS Check Credit Card # __________________________________________________ CVV # _____________ (Required) VISA DISCOVER Expiration Date _________________ Signature _______________________________________________________________ Billing Address _____________________________ City ______________________ State ______ Zip Code _____________ Do not make flight or hotel arrangements until you have received a confirmation letter from Global Mini Implant Institute with the correct date and location. A letter of confirmation will be sent to you once your registration form has been submitted and payment approved. Please Note Cancellations two weeks prior to event will be subject to a 25% administration fee. Cancellations less than seven days prior to the event are non-refundable. If you have any questions call 800-848-5676. Terms and Conditions Call 800-848-5676 to reserve your space for these courses
