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(please print this page and use the forms for registration)
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DENTAL MANAGEMENT COALITION ANNUAL CONFERENCE 2008 |
| Name |
| Position / Title |
| Organization / Company |
| Mailing Address |
| City |
State |
Zip Code |
| Telephone (B) |
Fax |
| Telephone (H) |
Cell Phone |
| E-mail |
Special requests and list names of all extra adult guests plus children with their ages and birth dates:
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| Please enter amounts: (Fees will increase if register after March 1, 2008) |
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Fee for 4 day / 3 night program $1,099 plus DMC Annual Membership $50 |
$1,149.00 |
| # |
Extra Adults x $299 |
$ |
| # |
Children (age 15 & under) x $249 |
$ |
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Pre or post conference nights (please list dates) |
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Registrant $210 x number of extra nights |
$ |
| # |
Extra adults x $99 x number of extra nights |
$ |
| # |
Extra children x $60 x number of extra nights |
$ |
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GRAND TOTAL if paying by check |
$ |
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GRAND TOTAL add $50 handling fee for credit card payment |
$
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Registration fees are NON REFUNDABLE.
Please make check payable to: K L Travel Conference Account
and mail this form and check to: Conference Coordinator, c/o K L Travel, Inc.
322 Heathcote Road, Scarsdale, New York 10583
- or -
For credit card payments, a $50 handling fee will be added to the GRAND TOTAL amount.
Credit card charges will appear on statement as:
K L Travel, Inc. / IATA Ticketmaster Canada |
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| Fax credit card payment to: (914) 472-7431 |
| (please print clearly) |
| Name on Credit Card: |
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| Visa |
Mastercard |
Amex |
| Credit Card Number: |
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| Expiry Date: |
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| Signature: |
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