Registration Form - MU Conference Office

2015 MU/Zoetis Dental CE Weekend Registration Form
April 25-26, 2015
Name ______________________________ Last 4 digits of Social Security # (for CE Credit ) __________
Date of Birth (for CE Credit) ___________________________________________
Organization _____________________________________________________________________
Mailing Address ________________________________________________________________________
City_____________________________ State__________________ Zip____________
Daytime Telephone (_____) _______________________
E‐mail____________________________________________
Veterinary Registration Fee: (check one)
o $185 Sat. Lecture Only – 8 hours of CE
o $425 Sat-Sun Lecture and Wet Lab – 12 hours of CE
We can only accommodate 36 veterinarians for the wet lab. Registration will be first come, first served.
Veterinary Technician Registration Fee: (check one)
o $50.00 Lecture only – 4 hours of CE
o $125.00 Lecture and Lab – 8 hours of CE
All fees include continental breakfast, lunch and proceedings for those who pre-register.
Method of Payment:
 Check Enclosed (Payable to University of Missouri)
 Credit Card: 0 MC
0 Visa
0 Discover 0 AMEX
Card# _________________________________
Exp. Date _______
Authorized Signature ____________________
Printed Signature ________________________
Address if Different than Registrant _______________________________________________
If you require special assistance or services, or have food allergies/dietary restrictions, please contact the
MU conference Office at [email protected] or list here:
__________________________________________________________________________________
Ways to Register
Register on-line at: https://extweb.missouri.edu/NewWebReg/Login.aspx?uid=3&pid=125231
1.) Mail completed form and payment information to:
Dental CE Weekend; 344 Hearnes Center, Columbia, MO 65211
2.) Phone by calling (573) 882- 4349 or toll-free at 1 (866) 682-6663 with credit card information
3.) Fax completed forms with credit card information to: (573) 882-1953
Cancellation Policy: Refunds will be made if the MU Conference Office receives a written request by
April 17, 2015. We will make no refunds after this date, but substitutions are welcome.
By registering, you give your permission to distribute your name and contact information to conference attendees. If you prefer
not to be included in these distributed lists, provide a written request for your contact information to be omitted. Please email
request to [email protected]
Office USE ONLY: CEIS # 125231
Customer #______________
Receipt #__________________