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Be My Own Consultant Event Registration
Your Email
Receipts will be sent to this address.
.............................................How many attending?............
*Per Attendee Registration:
Spouse Event/Food fee:
Fees are per attendee
Please note any dietary restrictions or special arrangments:
How did you hear about our class?
Billing Information
Practice Name:
*First Name:
Middle Initial:
*Last Name:
*Address Line 1:Billing address
Address Line 2:Apt. or Suite No.
*Zip Code:
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
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.

I understand that I may adjust the number of attendees, reschedule or cancel at least 30 days prior to the course date without penalty. If I cancel with less than 30 days` notice prior to course date I understand that I will be charged a $250 administration/reservation 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
Symphony Dental - PO Box 604, Temple, Ga 30179 Phone 678.563.6122
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