2019 DSDS Annual Session Registration Form

Complete this information even if the doctor is not attending:

Doctor's Name:
Doctor's ADA Number:
Doctor's Address:
City:
State:
Zipcode:
Email:
(For reg. confirmation)
Phone:
Fax:
Home or Cell Phone:
(For emergency purposes)
  Doctor is attending the meeting.

OTHER PERSONS ATTENDING:

Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 
Name:
Position:
Membership:
 

REGISTRATION FEE: (Prior to May 1st)

Includes copy of Dave Weber’s latest book, “Leadership Redefined: The 12 X’s of Success for TODAY’s Leader”

DSDS/ADA Member ($330.00 per person)
Non-ADA Member ($430.00 per person)

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Staff/Student/Spouse ($190.00 per person)
Residents ($0.00 per person)

Yes, I/we will attend the Annual Business Session and DSDS President's Party on Thursday, May 9 ($50 per person - The Delaware Contemporary)

Doctor
Guest

TOTAL REGISTRATION $0

Refund Policy: All requests for refunds or cancellations must be received by May 1, 2019. No refunds will be given after that time. Each registration cancellation/refund will incur a $35 administrative fee. Registration funds are not transferable.

 
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Christiana Executive Campus
200 Continental Drive
Suite 111
Newark, Delaware 19713
Phone: 302-368-7634
Fax: 302-368-7669
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