REGISTRATION FORM - ULTRASONIC SCALER COURSE

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

Course Fee: $155

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

Course Name: Ultrasonic Scaler
Course Fee: $155
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 _______________________