CONTINUING DENTAL EDUCATION - UNC School of Dentistry ...
CONTINUING DENTAL EDUCATION - UNC School of Dentistry ...
CONTINUING DENTAL EDUCATION - UNC School of Dentistry ...
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21<br />
Registration<br />
<strong>UNC</strong> Continuing Dental Education<br />
Please make additional copies for each person registering<br />
First Name ___________________________________________________ MI ______ Last Name ___________________________________ Jr. / Sr.<br />
Is this your fi rst time registering for a <strong>UNC</strong> CDE course Yes No<br />
Dentist Team Member: RDH DA LT Other ____________________________________________________<br />
*CDE ID # ___________________________________________________ Male Female<br />
Preferred Name Badge _____________________________________________________________________________________________________<br />
Employer _________________________________________________________________________________________________________________<br />
Offi ce Address _____________________________________________________________________________________________________________<br />
City __________________________________________________ State __________ Zip ______________________County in NC _______________<br />
Daytime Phone (_____) __________________________________________ Fax (______) ________________________________________________<br />
Email Address _____________________________________________________________________________________________________________<br />
Course Information<br />
1<br />
2<br />
Course Code ____________________________________________________________________ Fee ________________________________<br />
Course Title _________________________________________________________________________________________________________<br />
Course Code ____________________________________________________________________ Fee ________________________________<br />
Course Title _________________________________________________________________________________________________________<br />
3<br />
Course Code ____________________________________________________________________ Fee ________________________________<br />
Course Title _________________________________________________________________________________________________________<br />
Payment Information<br />
Check # ____________________________________________ Check Amount $ _________________________________________<br />
Visa<br />
MasterCard # ___________________________________________________ Expiration Date _______________<br />
Fax:<br />
(919)<br />
966-8954<br />
Cardholder’s Name____________________________________________________Cardholder Billing Zip Code ________________<br />
I have special needs. Please contact me.<br />
* Your CDE ID # can be found on previous course confi rmations and/or receipts.<br />
Date Received (<strong>of</strong>fice use only) _____________________________________
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