PDM Registration Form
PDA/ADA
Member Dentists
Select Courses
Non-Member Dentists Hygienists, Assistants,
Non-Licensed Staff
and Guests
By 3/20
By 3/20 After 3/20
By 3/20
Friday, April 5
Welcome Reception @ 8:30 p.m. m $25 m $25
m $25
m $25
m $25
m $25
Saturday, April 6
Drugs and Supplements CE @ 8:00 a.m. (4 hours of CE) m $200 m $280
m $300
m $420
m $130
m $180
Saturday April 6
Volunteer Dental Projects @ 8:30 a.m. m $0 m $0
m $0
m $0
m $0
m $0
Saturday, April 6
Perio @ 1:30 p.m. (3 CE credits) m $200 m $280
m $300
m $420
m $130
m $180
Saturday, April 6
Additional Tickets for Lunch @ 12:30 p.m.
NOTE: lunch is included with the fee for the
perio CE course m $40 m $40
m $40
m $40
m $40
m $40
Saturday, April 6
PDA Legislative Update @ 1:30 p.m. m $0
m $0
Not Available
Not Available
m $0
m $0
Saturday, April 6
PDA Business Meeting @ 2:15 p.m. m $0 m $0
Not Available
Not Available
m $0
m $0
Saturday, April 6
Council of Presidents’ Meeting @ 4:45 p.m.
Open to presidents and presidents-elect of district
& local dental societies m $0 m $0
Not Available
Not Available
Not Available
Not Available
After 3/20
After 3/20
Total Due $ ______________________________________________________
Method of Payment
Please make check payable to: PDA and mail with completed form
to P.O. Box 3341, Harrisburg, PA 17105 or fax your registration to
(717) 232-7169 or register online at www.padental.org/PDM
m Check m MasterCard m Visa m American Express m Discover
CARD NUMBER
EXP. DATE
Registrations accepted until March 25, 2019. Cancellations must be
received in writing by March 28, 2019. No refunds will be issued for
registrations cancelled after March 28. Cancellations can be faxed to
(717) 232-7169 or emailed to [email protected].
Questions?
Contact Rebecca Von Nieda at (717) 234-5941, ext. 117
or [email protected].
SIGNATURE
PRINT NAME AS IT APPEARS ON THE CARD
N OVEM BER/DECEM BER 2018 | P EN N SYLVAN IA DEN TAL JOURNAL
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