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Symphony Dental Education Event Registration
 
 
Your Email
Receipts will be sent to this address.
E-Mail:*
Registration
 
.............................................How many attending?............
Per Attendee Registration:*
Fees are per attendee
Total:
 
 
5 PACE CE CREDITS (MANAGEMENT/LECTURE)
 
How did you hear about our class?
 
Billing Information
Practice Name:
First Name:*Same name as on your card
Middle Initial:
Last Name:*
Address Line 1:*Where your statement is mailed
Address Line 2:Apt. or Suite No.
City:*
State:*
Zip Code:*
Phone:*
Credit Card Information
Cardholder Name:
Card Number:No dashes or spaces please
Expiration Month:From your card
Expiration Year:From your card
Card Type:
Card Validation Code:3-digit MC/VISA, 4-digit Amex
 
Agreement
By checking the box below and entering my name, I authorize Symphony Dental to process my payment immediately to reserve my attendance at this event.

Checks should be written to Symphony Dental and mailed to Symphony Dental, PO Box 604, Temple, GA 30179.

I understand that I may adjust the number of attendees, reschedule or cancel at least 14 days prior to the course date without penalty. If I cancel with less than 14 days` notice prior to course date I understand that I will be charged a $50 administration fee per attendee and refunded the balance paid. No refunds will be issued on or after the course date.
 
I understand and agree to the above terms*
Name*
Date*
 
 
Symphony Dental - PO Box 604, Temple, Ga 30179 Phone 678.563.6122
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