Registration | Wake Smiles

Wake Smiles Third Annual Continuing Education Program

3 Credits

November 16, 2018
8:00 am-12:30 pm
McKimmon Center
1101 Gorman St.
Raleigh, NC 27605

Registration Form

Name*

Organization

Mailing Address:

Street*

City*

State*

Zip*

Phone*

Fax

Email Address*

Dentist Fee $150.00

Staff Fee $100.00

DONATION

Dentists

Number X $150.00 = $

Staff

Number X $100.00 = $

Donation

Total Enclosed

To register and pay online - Complete information below and mail to above address or FAX to 919 803-3091

Card Type*

Name as it appears on Card*

Card Number*

Expiration Date*

Billing Address

Your gift is tax deductible to the full extent permitted by law. Raleigh Wake County Dental Society Community Dental Health Program, Inc. (Wake Smiles) is a qualified charitable organization under section 501(c)(3) of the Internal Revenue Code. Financial information about this organization and a copy of its license are available from the State Solicitation Licensing Branch at 919-807-2214. The license is not an endorsement by the State.