Dockstader Orthodontic Symposium

Full Name:
Required Email:
License No:	* mandatory field for dental professionals
Address:
City:
State:
Zip Code:
Country:
Choose Seminar: please choose one	There are no seminars for 2008 for now. Please check back later. Thank you. Level 1 - Fresno: $3,500 Level 2 - Fresno: $3,500 Level 3 - Fresno: $3,500
Please choose one of the options below:
	Sign me up. Full payment of $3,250 enclosed. (Immediate discount - $250 received)
	Sign me up. $500 down payment enclosed. Followed by 5 equal automatic credit card payments of $600 - due on the 1st of every month.
Assistants are welcome!
	Sign up my Assistant. 4 sessions for $1,500 per person $375 down payment enclosed. Followed by 5 equal automatic credit card payments of $225.

Payment Method:
	Will send check by mail. Payable to: Dockstader Dental Lab-Clinic 340 West Cromwell Ave Fresno, CA 93711
	Call me. To arrange for payment over the phone, please fill in tel. no. below.
Phone:	Ex. 510-555-5555
Comments:	Remember to include comments to advise us of your choice to pay by installments, or take advantage of our full payment discount. Please enter your comments or question here.
	Please include me on your mailing list for updates on any new products & services, promotions or events held by Dockstader Orthodontic Lab, Inc.