Winter Clinic Programme - Toronto Academy of Dentistry

Invisalign®Clear Essentials IREGISTRATION FormInvisalign® Clear Essentials IREGISTRATION FORMGet certified at Winter Clinic!Get Certified at Winter Clinic!Invisalign® Clear Essentials I1-day Limited attendance 1-day program Limited in conjunction attendance program with Winter conjunction Clinic with Winter ClinicNovember 4, 2011 │8:00am November – 4, 122011 noon | 8:00am continuous – 12noon 1:30pm continuous – 5:00pm 1:30pm │Room – 5:00pm 701B | Room 701BRegistration fee for one dentist and 4 team members$2080.00 Canadian Funds(Includes HST, course materials, lunch and participation at Winter Clinic)The registering dentist must be a resident of Canada or the United States of America.Dentist Name:Address:City/Prov/State:Postal/Zip Code:Tel:Email:Fax:Team Members: First Name Last Name TitleOffice MGR/ ODAA / ODHA1. Office MGR/ ODAA / ODHA2. Office MGR/ ODAA / ODHA3. Office MGR/ ODAA / ODHA4. Please make cheque payable to:Toronto Academy of Dentistry c/o ShowcareSuite 101-2770 14 th Avenue, Markham, Ontario L3R 0J1Total Funds Paid: $2080.00I wish to pay the above total by: MasterCard VISA Cheque #Name of Card Holder as it appears on card:Card Number:Expiry Date:Signature:Practice Name:Office Address:Suite:Prov./StateBus. Phone:Email:City:Postal/Zip Code:Fax:Cell:Contact information data is collected for registration purposes and will be shared with Align Technologies for recognition of courseattendance.Signature:__________________________________________________________32www.tordent.com