Introductory One day orthodontic seminar: "Is ortho for me?"…………... $99

Fundamental Orthodontics-one year (4 session course)…………………$3,950

Intermediate Orthodontics-one year (4 session course)…………………$3,950
 students must have completed Fundamental Orthodontics to enroll.

Name______________________________________________________________

Address____________________________________________________________

City____________________________State______________Zip______________

Phone______________Fax_______________email_________________________

Send this form with check to:

IAO NE c/o Dr. Keith Hollinger
79 Maple Street
East Longmeadow, MA 01028

____$3,950 (4 session course)

____$99.00 one day informational session
8:30 AM - 1:30 PM (check one session only)
Sat, May 5, 2012, Windsor Locks, CT ______
or
Sat, June 2, 2012, Albany, NY _________

OR Fax with credit card information to: 413-525-5280

CC # _ _ _ _ - _ _ _ _- _ _ _ _ - _ _ _ _ Exp. Date _____/_____