LDA Last Chance Seminar Registration

Friday, December 13, 2013

Renaissance Hotel
Baton Rouge, LA

*First Name:
*Last Name:
*Phone Number:
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C.E. Seminars
Fee Per Person
# Attending

LDA Members
ADA Members
Assoc. Members
Dental Staff
Ret. Vol. Lic.
Dental Student
Free - You must register.
2013 Dental School Graduate
*Add LATE FEE of $25 per person after Nov. 22
$15 Credit card convenience fee

Total amount of fees due to the LDA =
(Please enter your total)

Please list names of anyone registering with you:

I will pay by: Check or Credit Card

If paying by check, please mail to:

Last Chance Seminar
P.O. Box 261173
Baton Rouge, LA 70826-1173

If paying by credit card,
please enter the information below:

Visa/Master Card Number:
Expiration Date:
Name as it appears on card:
3 digit security code on back of card:

Questions or Comments:

NOTE: There is a $15 non-refundable convenience fee for each credit card transaction.

C.E. registration includes lunch and continental breakfast.

Cancellation Policy:
After November 22, 2013, refunds will be given only with the approval of the LDA Council on Dental Education. In the unlikely event the meeting is cancelled, all C.E. registration fees will be refunded, less proportional costs of materials already produced and distributed.