ADE Seminars Course Registration Form

Print form, complete and either fax to 301-862-1981 or mail to
Dr. Emma Galvan, Course Director, 10635 Gramercy Place, Suite 339, Columbia, MD 21044

Academy of General Dentistry Approved

1/1/2007 to 12/31/2010

Product Quantity Unit
Price		 Price
 
      
 
      
 
      
  Total: $0.00 USD

Contact Information

Name: __________________________________________________________________________
Specialty: _______________________________________________________________________
Phone: _________________________________ Fax: ____________________________________
Email: __________________________________________________________________________

Billing Address

Address 1: ______________________________________________________________________
Address 2: ______________________________________________________________________
City: __________________________________ State: ____________________________________
Country: _______________________________ Zip Code: ________________________________

Payment Information

Your card will be charged the full course fee.
Payment Method:     Visa       MC       Enclosed Check
Name On Card: __________________________________________________________
Credit Card #: ___________________________________________________________
Exp Date: _____________________ CVV#: _________(3 digits on back of card)
Signature: _________________________________________________ Date:__________________

In case of cancellation by registrant, refunds will be made if received in writing NO LATER than four weeks prior to start of course date. A $50 processing fee is charged on refunds. In the rare event that attendance is insufficient, participants will be notified of cancellation or reschedule one month prior to course date and a full refund will be given. In such circumstance, organizers will not be held liable for any expenses already incurred by any participant. Advanced Dental Education Seminars, LLC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of ADE Seminars, LLC are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry. The current term of approval extends from 1/1/2007 to 12/31/2010.