Mail-In Registration Form

Please fill out the form as completely as possible.

Dr. Mr. Ms. Name:

DDS DH DA DLT Specialist or Other:

Name of the practice or dentist (if business address):

Mailing Address and Suite #:

City:

State: Zip Code: Country:
Birth Year: Email:
Office Phone: Home Phone:

I am a University of Minnesota School of Dentistry graduate: Yes No
Year of graduation:

I have enclosed $ of Fees for Course number:
Course (name):

Payment Method: Visa MasterCard Discover American Express Check
Card Number : Exp. Date:
Date: Signature:

Make payable to the University of Minnesota and mail with check or credit card information to:

Continuing Dental Education
6-406 Moos HS Tower
515 Delaware St. SE
University of Minnesota
Minneapolis, MN 55455

or FAX with credit card information to (612) 624-8159.

For lecture and participation course registrants only:

Please send me additional information on hotel/motel accomodations. Yes No

I wish to register as a School of Dentistry Alumni Society member. Yes No
(You may deduct 10% of the tuition from the cost of lecture-only courses.)

I wish to register as School of Dentistry faculty/staff (space available bases).
Division:
I am: full-time faculty part-time faculty graduate student staff

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The University of Minnesota is an equal opportunity educator and employer.	Last modified on Tuesday Aug 08, 2006