Dr. Howard Farran: One Day Dental MBA
May 16, 2014
Cedarbrook Lodge
18525 36th Avenue South
Seattle, WA 98188-4967
206.901.9268
9:00 AM – 4:00 PM
7 CDE Credits
•
•
Continental breakfast and lunch included
Parking included with registration
12th Annual William Howard
Memorial Lecture
REGISTRATION INFORMATION
Name
Billing Address
City / State / Zip
Phone / Fax
Email (required)
Additional Name
Additional Name
Additional Name
Additional Name
Please list any accommodations you may require:
[ ] Vegetarian
[ ] Vegan
[ ] Other
PAYMENT INFORMATION
Type
Qty
Member in both ADA and AGD
Before 5/9/2014
$199
After 5/9/2014
$249
$
Member in ADA Only
$250
$300
$
Member in AGD Only
$250
$300
$
Staff with Member in both ADA and AGD
$125
$175
$
Staff with AGD Member only
$175
$225
$
Staff with ADA Member only
$175
$225
TOTAL
$
[
Payment Method
] Visa
[
] Master Card
Card Number:__________ - __________ - __________ - __________
[
Total
$
] Check #
Expires ________ / ________ CVC_________
Cancellation Policy: Seattle King County Dental Society will refund 85% of any registration fees so long as we are contacted by letter or phone two
business days before the event. After that time, no refund is available. Please see our complete cancellation policy in the Membership Guide.
FOR STAFF USE ONLY
Payment processed __
TS Entered ________
□
□
2201 Sixth Ave, Suite 1210
Seattle, WA 98121-1857
206.448.6620
FAX 206.443.9308
Academy of General Dentistry Approved PACE
Program Provider. FAGD/MAGD Credit Approval
does not imply acceptance by a state or provincial
board of dentistry or AGD endorsement.
2011 to 2015
AGD Provider ID 3193

This Changes Everything” “

MD AGD Officers - Maryland