Registration forms
for VHCTAz continuing education programs
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Fax registration with credit card information to AzVMA 602.249.3828
or mail with check to: AzVMA,
100 W. Coolidge St., Phoenix, AZ 85013
Questions? Call AzVMA at 602.242.7936
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|
Office Manager's Luncheon:
6/18/08
VHCTAz member: $12
Non-member: $47 (includes optional 1-yr VHCTAz membership)
| I
require a vegetarian meal. |
| I
prefer to waive my 1-yr membership and register at the
non-member fee. |
|
| Name: |
| Hospital: |
| Phone:
Fax: |
| Visa or MC#: |
| Exp. Date:
Amount: |
| V-code: (Last 3
digits on the back of the card near the signature box): |
| Credit card
billing address zip code: |
| Credit card holder's name: |
|
Signature: |
|
See above for fax number or address. |
Dental Radiology & Improving Dental Compliance: 6/19/08
VHCTAz member: $40
Non-member: $75 (includes optional 1-yr VHCTAz membership)
| I
require a vegetarian meal. |
| I
prefer to waive my 1-yr membership and register at the
non-member fee. |
|
| Name: |
| Hospital: |
| Phone:
Fax: |
| Visa or MC#: |
| Exp. Date:
Amount: |
| V-code: (Last 3
digits on the back of the card near the signature box): |
| Credit card
billing address zip code: |
| Credit card holder's name: |
|
Signature: |
|
See above for fax number or address. |
