To register, complete and email this form, or call us at:

Phone: 800-828-7626 (U.S. & Canada) or 716-871-1161 (worldwide)

Hours:

Monday - Thursday from 8:00a.m. to 6:00p.m. (Eastern Standard Time) Friday from 8:00a.m. to 5:00p.m. (Eastern Standard Time)

Click here for information about the speakers, what will be covered, and the agenda.

Multiple attendees may be registered on the same form as long as it is billed to the same credit card. Otherwise please complete separate registration forms for each attendee.

Thank You.

Attendee Information (Fields marked with an asterisk * are required)

Attendee #1 * Micro Implant Lecture & Hands-On Course Laser Sharp Orthodontics Course Both *First Name: *Last Name: *Practice/Business Name: *Type: Choose One Doctor Student Staff Attendee #2 * Micro Implant Lecture & Hands-On Course Laser Sharp Orthodontics Course Both *First Name: *Last Name: *Practice/Business Name: *Type: Choose One Doctor Student Staff Attendee #3 * Micro Implant Lecture & Hands-On Course Laser Sharp Orthodontics Course Both *First Name: *Last Name: *Practice/Business Name: *Type: Choose One Doctor Student Staff Attendee #4 * Micro Implant Lecture & Hands-On Course Laser Sharp Orthodontics Course Both *First Name: *Last Name: *Practice/Business Name: *Type: Choose One Doctor Student Staff

Address Information

*Address:   *City: *State/Province: ---SELECT STATE--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------------- AA AE AP --------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ---------------------- Other *Zip: *Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsraelItalyJamaicaJapanJordanKazakstanKenyaKiribatiKorea, Democratic People's Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SaharaYemenYugoslaviaZambiaZimbabwe * Phone: () - - Ext: Fax: () - - *Email:

Payment Information

Fees Doctor: Student: Staff: $195.00 per course $150.00 per course $125.00 per course Attend both courses - receive 15% off   Cancellation Policy: Full credit for cancellations made by 4/17/08, 50% credit by 5/2/08. No refunds after 5/2/08.     * Bill My Credit Card: Choose Type VISA MasterCard American Express * Credit Card #: * Credit Card Expiration: Choose Month January February March April May June July August September October November December  /  Choose Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 * CVV Security Code: (What's this?)   This number is printed on your MasterCard & Visa cards in the signature area on the back of the card. (It is the last 3 digits after the credit card number in the signature area of the card). For American Express cards, you can find your four-digit card verification number on the front of your credit card above the credit card number on either the right or the left side of the card. * Signature: (Name as shown on card)   By typing your name, you validate the ordering information is correct, and you authorize the charge to your card for the order price and shipping price.   Person to contact with any questions: Comments or additional instructions: