NMDA Fiesta Registration Kit 2021

6 2021 Fiesta NMDA June 17–19, 2021 New Mexico Dental Association is an ADA CERP Recognized Provider 2021 FIESTA NMDA HYBRID - Registration Form Register Online at www.nmdental.org 1. Send Registration Materials To: Register once only: if you register twice (i.e. mail and online) you may be charged twice. Primary Registrant: Mailing Address: City: State: Zip: Day Phone:( ) Email: June 17-19, 2021 Albuquerque Convention Center, Albuquerque NM - Hybrid 2. Names: (print or type clearly - errors can lead to delays in processing) Registrant Type Fee Tick- eteted Event Code Fee Tick- eteted Event Code Fee Tick- eteted Event Code Fee Tick- eteted Event Code Fee Tick- eteted Event Code Fee TOTAL 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Questions? Call, write or email us! New Mexico Dental Association, 9201 Montgomery Blvd. NE, S. 601, Albuquerque, NM 87111 Ph (505) 294-1368 - Fx (505) 294-9958 - E-mail: narenas@nmdental.org 3. Total Fees & Payment Method Total Payment Due: Check #: Check Amt: Visa MC AmEx C.C. Amt. Credit Card #: Exp. Date: Signature: Print - Name on card: 4. Mail to: NMDA , 9201 Montgomery Blvd NE S. 601, Albuquerque, NM 87111 or FAX: (505) 294-9958 (PLEASE KEEPA COPY FOR YOUR RECORDS)