School of Dentistry

Continuing Dental Education

Providing timely and practical continuing education for dental professionals

Mail-in Registration Form

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Mail-in Registration Form

 

Please fill out the form as completely as possible.

Dr. Mr. Ms.   Name:

DDS DH DA  DLT  Specialist or Other:

Name of the practice or dentist (if business address): 

Mailing Address and Suite #: 

City:

State:  Zip Code:  Country:
Birth Year:   Email:
Office Phone:    Home Phone:

I am a University of Minnesota School of Dentistry graduate:      Yes   No
Year of graduation:   

I have enclosed $ of Fees for Course number:
Course (name):

Payment Method: Visa  MasterCard  Discover  American Express  Check
Card Number :  Exp. Date:
Date:  Signature:

Make payable to the University of Minnesota and mail with check or credit card information to:

Continuing Dental Education
6-406 Moos HS Tower
515 Delaware St. SE
University of Minnesota
Minneapolis, MN 55455

or FAX with credit card information to (612) 624-8159.

For lecture and participation course registrants only:

Please send me additional information on hotel/motel accommodations.       Yes   No

I wish to register as a School of Dentistry Alumni Society member.     Yes   No
(You may deduct 10% of the tuition from the cost of lecture-only courses.)

I wish to register as School of Dentistry faculty/staff (space available bases).
Division:   
I am: full-time faculty  part-time faculty graduate student  staff

 

 

 



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  • The University of Minnesota is an equal opportunity educator and employer
  • Last modified on July 2, 2012