Annual Session Registration Form

This form is for paying by credit card only. If you want to pay by check or purchase order, you must download the Registration Form PDF, fill it out and mail it to us. We cannot accept an online registration for checks. Thank you.

If using a check, email DSDSTOM@comcast.net to be placed on attendance list!

Mail: DSDS, 892 Eichele Road, Perkiomenville, PA 18074

Name:
Title:
Membership Type:
Employer's Name:
(Staff registrants only)
Office Address:
City:
State:
Zip Code:
Office Phone:
Emergency Phone:
Email:
(Registration Confirmation will be sent via Email Only one week prior to the course)

REGISTRATION FEE:

President's Reception 7:00 PM - 10:00 PM

$65.00

DSDS Business Meeting 6:00 PM - 7:00 PM

Other Attendees:

TOTAL REGISTRATION $0.00

 
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Delaware State Dental Society
892 Eichele Road
Perkiomenville, PA 18074-9510
Phone: 302-368-7634
Email:
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