MICHIGAN DENTAL SEMINARS

P.O. Box 180156 • Utica, MI 48318-0156 • 586-254-5544


Michigan Dental Seminars is an approved sponsor by the Michigan Board of Dentistry Continuing Education Program.


REGISTRATION FORM (please print)

Name:

Home Address:

City/State/Zip:

Home phone:

Work phone:

E-mail Address:

SS # or Professional License # (for CE Purposes):


Class:

Date:

Time:

Fee:

 

 

 

$

 

 

 

$

 

 

 

$

 

 

 

$

TOTAL:

$

Check or Money Order Enclosed (payable to Michigan Dental Seminars)

We do accept Visa/Mastercard
     Name on Credit Card: _____________________________________________________
     Credit Card Number: ______________________________________________________
     Expiration Date: ____________________________________

Please print this form, fill out, and send to:
Michigan Dental Seminars
P.O. Box 180156
Utica, MI 48315