Registration Information
Level 3 - Posterior Quadrant Proficiency
To expedite the process, please register by phone at 1.866.781.0072
or fill in your answers, print out the form and fax it to 1.480.588.9072
Today's Date: Feb 04, 2012
Course Date:
February 23 - February 24
March 22 - March 23
April 14 - April 15
May 17 - May 18
June 09 - June 10
July 14 - July 15
September 13 - September 14
November 08 - November 09
December 06 - December 07
Doctor's Name:
Mailing Address:
City:
State:
Zip:
Phone:
Fax:
Formal Name of Practice:
What is your CEREC experience level?
I have completed 0 to 50 CEREC restorations
I have completed 50+ CEREC restorations
Email:
Tuition:
$2,950 for doctors
$950 for team members
Full Name
Position
Fee
1.
2.
3.
4.
5.
6.
7.
Credit Card Payment: MasterCard - VISA - Amex
Credit Card:
Security Code:
Expiration Date:
Name on Card:
