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Registration Form

	AADR & ADEA, March 8–11, 2006, Orlando, Florida, USA

Top Aadr & adea, march...

1. Register online at www.one-stop-registration.com/aadr-adea/ or complete this form and submit it.
   
2. Each registrant must complete a separate form. Please photocopy the form if you need extra copies.
   
3. A registration received without payment or after February 6, 2006, will be charged onsite registration fees.
   
4. You must be a member of ADEA or AADR at the time you register to receive the lower member registration fee.
   
5. If you wish to join ADEA to take advantage of the lower fee, please activate your membership online at www.ADEA.org before registering. If your school or program is an ADEA Member Institution, you may join ADEA through its Open Membership System after January 1, 2006, at no charge.
   
6. If you are not a member by the time you register, you will be charged the nonmember registration fee. This additional charge will be deducted from your credit card. If you paid by check, you will receive an invoice with a balance due, which must be paid before the meeting or on site.
   
7. Requests for refunds for your registration must be received in writing on or before February 6. A $40 processing fee will be charged, and the refund will be processed after the meeting.
   
8. A letter confirming your registration will be sent to you within three days after your registration is received.
   

Return to:
AADR & ADEA

c/o Laser Registration

1200 G Street, NW, Suite 800

Washington, DC 20005-3967, USA

FAX: +1-514-228-3150

Questions?
Call: +1-888-834-4430 (toll free)

+1-514-228-3031 (outside North America)

Or e-mail: AADR-ADEA{at}laser-registration.com

Membership Information
IADR/AADR ID # P __ __ __ __ __ __ __ OR ADEA ID # _________________

Are you an AADR presenter? No or Yes, Abstract ID # __ __ __ __ __

Registrant Information
Last/Family Name_____________________________________________________________________________

First Name and Middle Initial ___________________________________________________________________

Company/Institution ___________________________________________________________________________

Department __________________________________________________________________________________

Street Address 1 ______________________________________________________________________________

Street Address 2 ______________________________________________________________________________

City ___________________________________________State/Province_________________________________

Country _________________________________________ Postal/ZIP code _____________________________

Telephone______________________________________FAX _________________________________________

E-mail _______________________________________________________________________________________

Emergency Contact Name: ____________________________________________________________________

Emergency Telephone: ________________________________________________________________________

For Office Use Only

Amount pd: $ ____________

CC Auth: $ _______________

CK # ____________________

Accompanying Person(s)
Last/Family Name __________________________________First Name_________________________________

Last/Family Name __________________________________First Name_________________________________

Last/Family Name __________________________________First Name_________________________________

Letter of Invitation?
Yes, I require an official letter of invitation to initiate the visa process.
(This letter will be sent to the registrant only and will not include accompanying persons.)

Date of Birth: _________________Passport #: ______________________________Nationality: _________________________________

Pre-registration Fee per Person (by February 6, 2006)

IADR/AADR or ADEA Member $325

Non-member $575

IADR/AADR or ADEA Student Member $ 80

Student Non-member $135

Retired Member complimentary

Accompanying Person $ 40

NOTE: On-site fee is $100 more than the Member and Non-member pre-registration rates (excluding student, retired, and accompanying persons)!

Questions?
Call: +1-888-834-4430 (toll free)

+1-514-228-3031 (outside North America)

Or e-mail:AADR-ADEA{at}laser-registration.com

Subtotal for Registration Fee: $

Special Events

Signature Series

Member $200

Non-member $325

Lunch & Learn (attendance limited)

Member $ 40

Non-member $ 50

Thursday (#1–13): 1st choice_________ 2nd choice_________

Friday (#14–26): 1st choice_________ 2nd choice_________

Faculty Development Workshops

Member $75

Non-member $150

Thursday (#1–3): 1st choice_________ 2nd choice_________

Friday (#4–7): 1st choice_________ 2nd choice_________

Saturday (#8–10): 1st choice_________ 2nd choice_________

Dental Materials Group Reception (Thursday)

# tickets______ x $10 per person = $_______ (students only)

# tickets______ x $25 per person = $_______

Discourse & Dessert (Thursday)

# tickets______ x $25 per person = $________

Hotel Debit Card ($75 value)

# cards_______ x $60 each =$ _______

"OdontoBlast" Dance Party (Saturday)

# tickets_______ x $35 per person = $________

Subtotal for Special Events: $

TOTAL AMOUNT DUE: $

PAYMENT INFORMATION
Check # ______ for $___________ enclosed (must be payable to the AADR, in US Dollars and drawn on a US bank)

Charge $ _________ to: American Express MasterCard VISA

(Note: The charge will appear as AADR on your statement.)

Card Number: ________________________________________________________ Exp:________
month/________
year

Cardholder Name (print): ____________________________________________________________________

Cardholder’s Telephone:__________________________________________

Cardholder’s E-mail: _____________________________________________

Signature:__________________________________________________ Date: __________________________

Billing Address:

Same as above

Street:_____________________________________________________________________________________

City, State/Country/Postal Code ______________________________________________________________

The AADR/ADEA reserves the right to charge the correct amount if different from the Total Payment listed above.

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