(please print this page and use the forms for registration)
DENTAL MANAGEMENT COALITION ANNUAL CONFERENCE 2010
 Name  Degree
 Position / Title
 Organization / Company
 Mailing Address
 City  State  Zip Code
 Telephone (B)  Fax
 Telephone (H)  Cell Phone
 E-mail
 List special requests; list names of adult guest; list names of children; list pre and/or post nights:



Please enter amounts:  (Fees will increase if register after May 1, 2010)
 
Fee for 3 days / 2 nights program $1,049 $               
Adult guest $99 $               
Children (18 years and under) number of children         x $59 $               
        (Maximum 2 adults and 2 children in one room)
Fee for 3 days conference only $699 $               
 
Pre or post conference nights (please list dates)                                                                          
number of extra nights         x $179 $                
 
GRAND TOTAL by check (payable to DENTAL MANAGEMENT COALITION) $                
GRAND TOTAL if paying by credit card, please add $50 handling fee $                
 
REGISTRATION DEADLINE: May 1, 2010

Registration fees are NON REFUNDABLE.

Please 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
 
Fax credit card payment to: (914) 472-7431
(please print clearly)
Name on Credit Card:                                                                                 
Visa                 Mastercard                 Amex                
Credit Card Number:                                                                                 
Expiry Date:                                                                                 
 
Signature of Cardholder:                                                                                 

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