Winter Clinic Programme - Toronto Academy of Dentistry

REGISTRATION FormFIRST REGISTRATION (Primary contact – or Single Registrant)Dr. / Mr. / Mrs. / Ms. Last Name First NameList All Registrants (including First Registrant above – to a maximum of four (4) registrations)Please photocopy this page for additional registrationsDr./Mr./Mrs./Ms.Last Name First NameODA/CAF Member#/CODE (if applicable)*Member of which TorontoComponent Society (if applicable)RegistrationCodeRegistrationFeeWORKSHOPSProgramCodePLEASE PRINT CLEARLYFeeTotalREGISTRATION CATEGORY Before midnight After midnightOct. 13, 2011 Oct. 13, 2011A Dentist ODA Member $330 $390B 50-Year/ ODA Member /TAD Honourary Life Member COMP COMPC Dental Student ODA Member COMP COMPD Dentist Out-of-Province/Country $400 $470E Dental Student Out-of Province Country $100 $170F Guest (Non-practitioner) Must register with a practitioner $110 $180G Dental Hygienist (Registering alone, without dentist) $160 $195H Dental Hygienist (Registering as a team, with dentist) $135 –I Dental Hygienist Student $50 $120J Dental Assistant, Office Manager, Receptionist $140 $185(Registering alone, without dentist)K Dental Assistant, Office Manager, Receptionist $110 –(Registering as a team, with dentist)L Dental Assistant Student $50 $120M Dental Technologist $170 $240N Dental Technologist Student $50 $120All Active Canadian Armed Forces should register in theirProfessional Category and use the Winter Clinic 2011 COMP COMPCode provided by the Unit Commander.LIMITED WORKSHOPS/CONTINUING EDUCATION PROGRAMCode W1 Andreana - Laser (1:30pm–3:30pm) $50Code W2 Local Anesthesia (Feb 3, 2012) $100Note: Registrations for Invisalign Workshops on offered on a separate formGrandTotalI wish to pay the above total by:MasterCard VISA Cheque #_________________________________Cheques Payable to: Toronto Academy of DentistryName of Card Holder as it appears on card:Card Number:Expiry Date:Signature:Practice Name:Office Address:Suite: City:Prov./State Postal/Zip Code:Bus. Phone: Fax:Email: Cell:Confirmation will be sent to primary contact.Register Online at www.tordent.com (starting September 2, 2011)OR Fax to: 905.479.9404OR Mail to: TAD 2011 Winter Clinicc/o ShowcareSuite 101-2770 14 th Avenue, Markham, Ontario L3R 0J1Email: TAD@showcare.comAll fees are in Canadian dollars and include 13% HSTPAYMENT MUST ACCOMPANY EACH REGISTRATION FORM.CHEQUES PAYABLE TO TORONTO ACADEMY OF DENTISTRY.www.tordent.com 53