Level 1: professional Level 2: Level 3: Page Name: lawyer-online.aspx

Legal Questions? Ask a Lawyer: A Program for New Dentists*
Reservation Form

This program is sponsored by the Philadelphia County Dental Society in cooperation with an Engagement Grant from the American Dental Association. The ADA requires that all of the information below be completed by program participants. Incomplete forms will not be processed for registration.

*New Dentists are defined by ADA as dentists who have graduated within the last 10 years

Use a SEPARATE reservation form for each person.

Individual Information

Name:
ADA #:
Address:
City, State, Zip Code:
Work/Office Phone:
Personal Phone:
Non-School Email:

Additional Information

I am a CURRENT MEMBER OF:

Dental School & Year of Graduation:

Postgraduate Program:

Completion Date:

I have a current Pennsylvania dental license:

I have a current dental license in the following state(s):

I currently practice/plan to practice in:

Office address:

Other location:

Optional Questions

You may submit up to 2 questions you would like the speaker(s) to address:

Question #1

Question #2

SECOND & FINAL SESSION:
OCTOBER 3 - 6:30 T0 9:15 PM

DAVE & BUSTER'S
325 NORTH COLUMBUS BLVD., PHILADELPHIA, PA 19106

REGISTRATION INCLUDES REFRESHMENTS & FREE PARKING (Parking is $15.00 prepaid as you enter. Bring your receipt to the session. We will arrange to reimburse your credit card.)

Register me for Wednesday, October 3
$15.00
$20.00
None

Payment Information

Total Payment
CC Account #
Credit Card Type
Expiration Month
Expiration Year

The Philadelphia County Dental Society neither expresses nor implies that specific courses will fulfill various state continuing education requirements.
Consult the regulations pertaining to the requirements of your state.

Philadelphia County Dental Society
One Independence Place
241 South 6th Street, Unit #C3101
Philadelphia, PA 19106
Telephone: (215) 925-6050 Fax: (215) 925-6998

General Information, Questions, Comments: info@philcodent.org
©2000-2010 Philadelphia County Dental Society Disclaimer