"HAVE FUN WITH LASERS an Introduction to Lasers in Dentistry"
HAVE FUN WITH LASERS an Introduction to Lasers in Dentistry 12th ANNUAL ALD CONFERENCE & EXHIBITION APRIL 6-9, 2005 Marriott New Orleans • New Orleans, LA Pre-Conference Program: Have Fun with Lasers, April 5, 2005 EARLY REGISTRATION IS STRONGLY ENCOURAGED. SPACE IS LIMITED. APPLICATIONS WILL BE PROCESSED IN THE ORDER RECEIVED. Please print or type below (as you would like it to appear on your badge): ________________________________________________________________________________________________________ Last Name First Name Degree/Credential (e.g., D.D.S.) _________________________________________________________________ Office Address City State/Province Postal Code Country _______________________________________________________________________ Office Phone Fax Number Home Phone E-mail Address COURSE FEES* (U.S. Dollars) - Have Fun with Lasers, an Introduction to Lasers in Dentistry, Tuesday April 5, 2005, 8:00am-3:00pm Single participant $300 $ _________ Group Office Rate (3-5 individuals) $750 $ _________ Standard Proficiency Certification Program. Optional CE for Have Fun with Lasers participants Tuesday April 5, 2005, 3:30pm-7:30pm, Wednesday April 6, 2005, 7:30 am-6:30pm I am interested in participating in the Standard Proficiency course only $450 $ _________ I am interested in participating in the Standard Proficiency Certification Program (course & exam)*. Subject to Conference participation and Membership registration. ** These special rates are only available to those participating in Introductory Course $275 $ _________ (*)Academy Membership is necessary to obtain a Certificate issued by the ALD I am a current member of the Academy Yes No If No, I enclose dues for membership (valid thru Dec. 2005) Fee: $350 $_________ TOTAL DUE $_________ PLEASE PRINT OR TYPE YOUR NAME:_______________________________________________________________________________ PAYMENT METHOD: (check one) Check or Money Order payable in U.S.Dollars to “Academy of Laser Dentistry” in the amount of $___________ VISA ($__________) MasterCard ($__________) Amex ($__________) ____________________________________________ ___________________________________ Credit Card Number PRINT CLEARLY Expiration Date ____________________________________________ ___________________________________ Signature of Cardholder Printed Name of Cardholder See separate conference registration forms. ** Candidates re-taking Standard Proficiency examinations are obligated to pay the appropriate fees and will receive the comprehensive examination package. *** Non member Candidates must complete membership application to receive recognition from the Academy of Laser Dentistry along with official certificate. See Fee Categories on Membership Application and send completed membership application along with this form. CANCELLATION POLICY: For written cancellations received by March 1, 2005 a full refund will be issued less $150 administration and materials fee. No refunds will be issued after March 1, 2005. RETURN FORM TO: Academy of Laser Dentistry, Certification Registration, PO Box 8667, Coral Springs, Florida 33075 USA Telephone (954) 346-3776 Fax (954) 757-2598 Email firstname.lastname@example.org.