Return to NSDHS Home


Mail-In Registration Form

 


Topic:
Mega Issues Forum
Speaker: North Suburban Dental Hygienists Society
When:
 Wednesday, May 2, 2012 - 3 CE Seminar
Time: Sign-in Begins at 6:00pm
 Seminar begins promptly at 6:30pm - 9:30pm

Mail-in Registration Deadline:
Mail-in Registration must be postmarked NO LATER THAN Wednesday, April 25, 2012

This meeting is held at the Bristol Court Banquet Hall adjacent to the Mt. Prospect  Plaza. Bristol Court  is located at 828 Rand Road, Mt. Prospect, IL (between WalMart and Menards). Bristol Court phone number is (847) 577-6055 (Bristol Court does not provide information on NSDHS seminars).

First Name
Last Name
RDH License #: 020-
(Required)
  Dentist License #: 019-
  (if attending) 
  Phone:
  E-mail Address: 
necessary for handouts   
Dinner Entree:
Chicken Marsala   OR   Veggie Lasagna

ADHA Member $29.00
(All ADHA members need to have their 2012 dues paid up to date to be eligible for member status)

Membership will be verified; if you are unsure of your ADHA membership status, you may click to contact ADHA membership services or call (312) 440-8900

Non-ADHA Member/Dentist/DentalAuxiliary/Guest $51.00

  • Please fill out and print this form
  • Make checks payable to NSDHS
  • Mail registration postmarked NO LATER THAN Wednesday, April 25, 2012 to:

NSDHS
P.O. Box 8332
Rolling Meadows, IL 60008

If you have questions, please contact seminar coordinator Laura Burke, RDH at LBurkeRDH@yahoo.com

 Return to NSDHS Home