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“Mastering Mini Dental Implants”

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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


				
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