JOIN NOW
TEXAS REGIONAL SSC MEETING
Please use this form to register for the Texas Regional SSC Meeting.
Symposium Tuition
Registration fee was included in your Lone Star Dental Seminars 2016 -2016 tuition.
Registration Fee
$0.00
Registration fee was included in your Lone Star Dental Seminars 2016 -2016 tuition.
REGISTRATION INFORMATION
Practice Name
*
Practice Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Registrant Name
*
First
Last
Registrant Email
*
Office Phone
*
Fax
Cell Phone
Arrival Date
Date Format: MM slash DD slash YYYY
Departure Date
Date Format: MM slash DD slash YYYY
Accommodations
Ritz-Carlton, Dallas
Other
Please specify location
Shirt Type
Women's
Men's
Shirt Size
XS
S
M
L
XL
XXL
Any special dietary requirements?
Yes
No
Please specify any registrant dietary requirements
GUEST INFORMATION
Do you plan to bring a spouse/guest to any events?
Friday Keynote (includes breakfast)
Friday Night Event
Saturday Session (includes breakfast + lunch)
All
Guest Name
Any guest special dietary requirements?
Yes
No
Please specify any guest dietary requirements
PAYMENT
Total Tuition Cost
$0.00
Payment Options
Check
PayPal
Once you submit your online registration, if any payment is due, please make your check payable to:
“Lone Star Dental Seminars”
And remit, to:
Lone Star Dental Seminars
ATTN: Susan Powell
1950 Round Rock Avenue
Round Rock, TX 78681
Once you submit your online registration, if any payment is due, please send a PayPal payment to:
rachel@naplesofs.com
