CDE Registration Form-Spring

Course Registration Form

TO ENROLL BY MAIL: Please fill in this Registration Form completely and send in with your payment (enrollment is not complete without payment) to the address below.
UTHSCSA Dental School
Office of the Dean
Continuing Dental Education MSC 7930
7703 Floyd Curl Drive
San Antonio, Texas 78229-3900

TO ENROLL BY PHONE: Please Call (210) 567-3177

TO ENROLL BY FAX: Please FAX your completed registration form to (210) 567-6807

People who are hearing or speech impaired may call TTD Message-Relay Texas at (800) 735-2989 or (800)735-2988.

Course Title
Course Date:
Course Fee:	() D.D.S. - () A.D.P. -
Last Name:
First Name:
Date of Birth:
Home Address:
City/State/Zip:
Office Address:
Suite #:
C/O:
City:
State:
ZIP:
Offce Phone:
Home Phone:
FAX No.:

Enclosed (Payable to UTHSCSA):	() Check ()Mastercard ()Visa ()Discover
Card No / 3-digit ID.:	/
Expiration Date:
Cardholder Name:

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We plan to make this form submit your registration directly to the Office of Continuing Dental Education in the near future.
Thank you for supporting CDE at the University of Texas Health Science Center at San Antonio Dental School.

For suggestions, comments, and concerns about this page,
e-mail us at: smile@uthscsa.edu

Last revised: November 30, 2006 by RO
© 2003 UTHSCSA Continuing Dental Education. All rights reserved.