2021 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:

DSDS/ADA Member ($335.00 per person)
Non-ADA Member ($435.00 per person)

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Staff/Student/Spouse ($210.00 per person)
Residents ($0.00 per person)

Thursday, May 13
Annual Business Session and President's Dinner FOR MEMBERS ONLY

Chase Center Christina Ballroom
Complimentary (Pre-registration required no later than May 7, 2021)

Yes, I will attend the Thursday Annual Session Dinner

Doctor

TOTAL REGISTRATION $0

Refund Policy: All requests for refunds or cancellations must be received by May 1, 2021. 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
Email: