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Annual Dental Review - UNC School of Dentistry - University of ...

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Registration<br />

30th <strong>Annual</strong> <strong>Dental</strong> <strong>Review</strong> at Myrtle Beach, SC<br />

thursday-Saturday, June 27-29, 2013 • Registration Deadline: June 17, 2013<br />

**Please duplicate form for each additional registration**<br />

Course Code: 13-OP-002<br />

Registration Fee: Dentist $495 Registration Fee: Team Member $285<br />

Single Day Rate: Thursday $190 Single Day Rate: Thursday $100<br />

Friday $190 Friday $100<br />

Saturday $190 Saturday $100<br />

First Name Last Name Jr. /Sr.<br />

Badge Name CDE ID# (if known) Male Female<br />

Employer<br />

Mailing Address<br />

City State Zip<br />

County in NC<br />

Daytime Phone (______)<br />

Fax (______)<br />

Email Address<br />

Check # Check Amount $<br />

**Please make checks payable to the <strong>UNC</strong> <strong>School</strong> <strong>of</strong> <strong>Dentistry</strong>.<br />

Register on-line with a Credit Card only for the full 3 day conference at<br />

www.dentistry.unc.edu/cde/courses<br />

Date Received (<strong>of</strong>fice use only)<br />

I have special needs, please contact me.<br />

The <strong>University</strong> <strong>of</strong> North Carolina at Chapel Hill is committed to equality <strong>of</strong> educational opportunity and does not<br />

discriminate against applicants, students, or employees based on race, color, national origin, religion, sex, age,<br />

veteran status, or disability.<br />

<strong>Dental</strong> education institutions have an obligation to disseminate new knowledge related to dental practice. In so<br />

doing, some presentations may include controversial materials or commercial references. Sponsorship <strong>of</strong> a<br />

continuing education course by the <strong>University</strong> <strong>of</strong> North Carolina does not necessarily imply endorsement <strong>of</strong> a<br />

particular philosophy, procedure, or product by this institution.<br />

By providing my information, I consent to receive communications via mail, email, fax, and phone from the<br />

<strong>University</strong> <strong>of</strong> North Carolina Continuing <strong>Dental</strong> Education <strong>of</strong>fice. The Continuing <strong>Dental</strong> Education <strong>of</strong>fice will not<br />

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