Mail to :
Dental Professionals of California
3144 North G Street, Suite 125-318, Merced, CA 95340

Fax to: (209) 722-3712
Call at: 1-800-438-7887

We accept the following methods of payment:
· Money orders
· VISA/Master Credit cards
                                                              


                REGISTRATION FORM - CORONAL POLISH COURSE

Name (please print) ________________________________
Social Security _________________________  RDA Number__________
Address_____________________________________________________________________
City ________________________________________________
State________      Zip __________
Employer ___________________________________
Home Telephone (   ) _________________   Fax (  )_______________
Work Telephone (   )__________________   E-Mail_________________

Course Fee: $310

In order to process your request, please print clearly the above
information and complete all spaces where applicable.

Course Name: Coronal Polish Course
Course Fee: $310
Location:
Number:
Date/s:

If payment is made via mail system, make money order payable to:
Dental Professionals of California
3144 North G Street, Suite 125-318, Merced, CA 95340

For Visa/Master Card Order Only
Name on Card _______________________________
Card Number ________________________________
Expiration Date_____________________________
Provide the 3 or 4 digit code that is on the back of your credit card _____


Authorized Signature _______________________