SECOND YEAR REGISTRATION FORM My AIO Email * Prefix (Dr, Mr, Ms, etc.) First Name * Last Name * Job Title * Company/Organization * Work Address * City * State * Choose... AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code * Country * Cell Phone * Work Phone * Home Phone Email * Website How did you hear about this seminar? * What would you like to learn from this seminar? * Enter the Entity you would like your CE credits reported to * (hold down CTRL key to select multiple options) AGD IAO CT State Dental NY State Dental Enter your AGD Number * Enter your IAO Number * Enter your ADA/CSDA Number * Enter your ADA/NYSDA Number * Dental School, Degree, & Date Completed * College, Degree, & Date Completed * Practice Type * Years in Practice * Orthodontic Courses Completed * Enter the letters/numbers from the box above* Click on the SUBMIT REGISTRATION button above to submit and pay for your registration. Your registration will not be processed unless payment has been received. Once you complete the payment process, you will see a confirmation message. Registration Cost Class Name Class Dates Location Instructor(s) Cancellation Policy: Full refund on or before July 15, 2023. Half refund between July 16-31, 2023. No refunds after August 1, 2023. Please make checks payable to:IAO New EnglandDr. David Levine, DDS888 Western AvenueAlbany, NY 12203518-435-1104 We also accept PayPal, search for IAONEWENGLAND.