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 – PIT AND FISSURE COURSE

Name (please print) ________________________________
Address_____________________________________________________________________
City ________________________________________________
State________      Zip __________
Employer ___________________________________
Home Telephone (   ) _________________   Fax (   )______________
Work Telephone (   )__________________   Mandatory E-Mail_________________

Course Fee: $400

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

Confirmation with exact location, time etc. will be sent via the e-mail system.

Course Name: Pit And Fissure Course
Course Fee: $400
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 _______________________

  

 

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