Registration Form

Please enroll me in:     (Right click to print)

Introductory One day orthodontic seminar: "Is ortho for me?"... $139

Fundamental Orthodontics-one year (4 session course)$3,950

Intermediate Orthodontics-one year (4 session course)$3,950
 students must have completed Fundamental Orthodontics to enroll.

Name______________________________________________________________

Address____________________________________________________________

City____________________________State______________Zip______________

Phone______________Fax_______________Email_________________________

Send this form with check to:

IAO NE c/o Dr. Keith Hollinger
79 Maple Street
East Longmeadow, MA 01028


____$3,950 (4 session course)

____$139.00 one day informational session
8:30 AM - 12:00 PM (check one session only)

Sat, May 6, 2017, Windsor Locks, CT ______
or
Sat, May 13, 2017, Lee, MA _________
or
Sat, May 20, 2017, Nashua, NH _________
or
Sat, June 10, 2017, Boston, MA _________
or
Sat, June 17, 2017, Albany, NY _________

OR Fax with credit card information to: 413-525-5280

CC # _ _ _ _ - _ _ _ _- _ _ _ _ - _ _ _ _ Exp. Date _____/_____

ACT NOW!
Respond by May 15th

Cancellation Policy: Full refund on or before July 15, 2017. Half refund between July 16-31, 2017. No refunds after August 1, 2017.
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