registration brochure - Florida National Dental Convention

2013 Florida National Dental Convention PRE-REGISTRATION
(DEADLINE for mail registration is Friday, May 31, 2013 – registration will not be processed after this date)
By registering for FNDC, I certify that I have read the cancellation policy and agree to abide by the terms and conditions of the policy.
Yes, I want to volunteer for PDC@FNDC.
FDA members, please check here if
interested in hosting a speaker at FNDC.
Please Print or Type
Payor Name (Primary Registrant)
Address (must include Suite/Apt if applicable)
City State ZIP Code
Phone (include area code)
Email
2. Practice
Type
(check one)
A ❑ General Practice
B ❑ Endodontics
C ❑ Oral Medicine
D ❑ Oral Pathology
E ❑ Oral Surgery
F ❑ Oral and Maxillofacial
Radiology
G ❑ Orthodontics
H ❑ Pediatric Dentistry
J ❑ Periodontics
Fax (include area code)
K ❑ Prosthodontics
L ❑ Public Health
M ❑ Dental School Faculty
N ❑ Dental Assoc. Admin.
P ❑ Retired
3. Registration Categories
* Refer to membership incentives in brochure.
** Employees of FDA member dentists are designated FDA Section Members.
*** Guests are the parents, spouse or over-18 children of registered attendee.
Code
Fee
(by 5/31)
Categories
Dentist/FDA Member FDA $0 $50
Dentist/FDA Member Applicant APP $30 $50
Dentist/ADA Member ADA $225 $245
Int’l Dentist/ADA Affiliate Member IAM $275 $295
Int’l Dentist/Non-ADA Affiliate Member INM $510 $530
Dentist/Non-ADA/FDA Member* DNM $480 $500
Dental Student/ASDA Member ASD $0 $30
Dental Student/Non-ASDA Member ANM $55 $75
Dentist/ADA/FDA Life Member DLM $0 $30
FDA Past President FPP $0 $30
FDA Past President Spouse FPS $0 $30
On site
Code
Fee
(by 5/31)
On site
Guest*** GST $30 $50
Section Hygienist SDH $30 $50
Section Chairside Assistant SDA $30 $50
Section Business Assistant SBA $30 $50
(office staff/manager)
Section Lab Technician SLT $30 $50
Non-section Hygienist** NSH $60 $80
Non-section Chairside Assistant** NSA $60 $80
Non-section Lab Technician** NSL $60 $80
Non-section Business Assistant** NSB $60 $80
Non-exhibiting Manufacturer NEM $550 $595
/Non-dentist
On-site registration and course fees are higher.
Save money and register early!
4. Primary Registrant
License No. Registration Registration Course/ Fee Course/ Fee Course/ Fee Course/ Fee Total
(required for reporting) Category Fee Event # $ Event# $ Event# $ Event# $
$ $ $ $ $
ADA No. (if applicable)
$ $ $ $ $
ASDA No. (if applicable)
5a. Additional Registrant
License No. Registration Registration Course/ Fee Course/ Fee Course/ Fee Course/ Fee TOTAL
(required for reporting) Category Fee Event # $ Event# $ Event# $ Event# $
$ $ $ $ $
ADDRESS CITy STATE zip PHONE EMAIL
5b. Additional Registrant
License No. Registration Registration Course/ Fee Course/ Fee Course/ Fee Course/ Fee TOTAL
(required for reporting) Category Fee Event # $ Event# $ Event# $ Event# $
$ $ $ $ $
ADDRESS CITy STATE zip PHONE EMAIL
5c. Additional Registrant
License No. Registration Registration Course/ Fee Course/ Fee Course/ Fee Course/ Fee TOTAL
(required for reporting) Category Fee Event # $ Event# $ Event# $ Event# $
$ $ $ $ $
ADDRESS CITy STATE zip PHONE EMAIL
PHOTO RELEASE: By registering for the 2013 Florida National Dental
Convention, I authorize the Florida Dental Association (FDA) the right
to photograph me, my invitees and guests while using common or
public areas of the hotel and to use the photographs in all formats
and media for any purpose, including for education, marketing
and trade purposes. I hereby release FDA from all claims arising
out of the use of the photographs, including without limitation all
claims for compensation, libel, invasion of privacy or violation of
copyright ownership.
6. Method of Payment Please print.
❑ Check: Make checks payable to the Florida Dental Association.
❑ Credit card: ❑ VISA ❑ MasterCard ❑ American Express If paying by credit card, only VISA, MasterCard and American Express are accepted.
Credit-card number:______________________________________________________________
Expiration date:____________________
Card holder (please print):______________________________________________________________________________________________
Signature:_____________________________________________________________________________________________________________
Grand Total $_________________
Register Online: www.floridadentalconvention.com
register By mail: Florida National Dental Convention
c/o Tradeshow Multimedia Inc.
4350 Renaissance Parkway, Ste. D
Warrensville, OH 44128