Registration Form
Please enroll me in:
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 _____/_____
ACT NOW!
Respond by April 15th
Cancellation Policy: Full refund on or before July 15, 2012. Half refund between July 16-31, 2012. No refunds after August 1, 2012.
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