First Name: Last Name: Office Address: City: State: Zip: Office Phone: Cell Phone: Email Address: Please Check: Oral Surgeon   Orthodontist   General Dentist   Other Please specify: Please list any dietary restrictions here:

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Course Registration   # of Attendees Fee Total

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Surgical Orthodontic Course x $2000 $0 Restorative Dentistry Course x $1600 $0 Auxiliary Staff - Surgical Orthodontic Course – with CE credit x $850 $0 Auxiliary Staff - Surgical Orthodontic Course – audit x $650 $0 Auxiliary Staff - Restorative Dentistry Course – with CE credit x $680 $0 Auxiliary Staff - Restorative Dentistry Course – audit x $520 $0 Resident Course Audit x $550 $0     Total Fee: $0 If you register more than one person, please enter name and contact information for additional people
(Name, office address, office phone, email, cell). The University of Iowa is not responsible for any non-conference activities or services offered by the resort.
The University makes no warranties or representations regarding the suitability or safety of the activities offered.