ARK-LA-TEX



ARK-LA-TEX

ACADEMY OF DENTISTRY

806 Medical Circle #200

Longview, TX 75605

Registration (903) 753-0337

Fax (903) 236-4537

THE ARK-LA-TEX ACADEMY OF DENTISTRY

PRESENTS

REGISTRATION FORM FOR

BREAD AND BUTTER ADHESIVE AND ESTHETIC DENTISTRY

BY

HAROLD HEYMANN

FRIDAY, FEBRUARY 19, 2010

CLARION HOTEL

SHREVEPORT, LOUISIANA

PROMPT STARTING TIME 8:30 AM

7 HOURS CONTINUING EDUCATION LECTURE CREDIT

REGISTRATION TO BE RECEIVED NO LATER THAN

5 DAYS PRIOR TO SEMINAR.

TO REGISTER YOU MUST MAIL OR FAX THIS COMPLETED FORM TO:

DR. CLINT BRUYERE, D.D.S.

806 MEDICAL CIRCLE #200

LONGVIEW, TX 75605

FAX (903) 236-4537

(Print Name)________________________________ [ ] I WILL ATTEND [ ] I WILL NOT ATTEND

PHONE: ______________________________

THESE STAFF MEMBERS WILL ATTEND:

1. ________________________________________

2. ________________________________________

3. ________________________________________

4. ________________________________________

5. ________________________________________

Dr. Non-Member Fee: $245 (Non-refundable-$45 if not received by deadline) Enclosed is my check for

Staff/Lab Tech (each): $35 (Non-refundable-$45 if not received by deadline) $____________.

The Ark-La-Tex Academy of Dentistry is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of the program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry. The current term of approval extends from October 19, 2003-October 18, 2006.

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