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AzAGD State Conference Application Form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Designation
*
DMD
DDS
RDH
Dental Auxillary
Dental Technician
Dental Student - ASDOH
Dental Student - MWU
Other:
AGD Status
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*Non-members who register to be an AGD member at the event will receive $100 off coupon towards any future AzAGD CE course!
AGD Student Member/Affiliate - $55
AGD Member - New Dentist $65
Faculty Dentist MWU/ASDOH - $65
AGD Member Dentist $75
Non-Member Dentist $175
Non-Member Hygienist $80
AGD Number, if applicable
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Mailing Street Address
*
Your answer
Mailing Address (City, State, Zip)
*
Your answer
Food Allergies
*
Your answer
Please read & initial: I understand that cancellations must be made at least 2 weeks prior to the event to receive 50% of my registration fee returned.
*
Your answer
Please read & initial: I understand that cancellations made after 2 weeks prior to the event will result in complete forfeit of my registration fee.
*
Your answer
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