Return to the ATSU Continuing Education website
Continuing Dental Education Registration Form
 Please submit one form per registrant
   
If you would like to register online using a credit card, please complete the information below:
   
  First Name:    
  Last Name:    
 
 Title:
  



 

  Speciality:  
  Mailing Address:    
  City:    
  State:    
  Zip:    
  Phone:    
  Fax:  
  Email (needed for course confirmation):      
   
 
 
Laser Workshop with Janet Press, RDH
8am - 4:30pm October 29, 2016
7 CEU

   
     
Subtotal: $0.00
Total: $0.00
   
   
 Credit Card Type:  
 Credit Card Number:   CID:  
 Credit Card Expiration: /
   
 Card Holder's Name:  
 Card Holder's Address:  
 City:  
 State   Zip:  
 Card Holder's Telephone: