10 2023 Fiesta NMDA May 18–20, 2023 New Mexico Dental Association is an ADA CERP Recognized Provider 2023 FIESTA NMDA- Registration Form Register Online at www.nmdental.org 1. Send Registration Materials To: (print clearly or type - materials will be mailed to this person/address) 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: May 18-20, 2023 Albuquerque Convention Center, Albuquerque NM 2. Names* (Print your name clearly - errors can lead to delays in processing and delivery of ce credit.) Registrant Type: Hyg/DDS/ etc. Individual’s email** Ticketeted Event Code Fee Ticketeted Event Code Fee Ticketeted Event Code Fee Ticketeted 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, Suite 601, Albuquerque, NM 87111 Ph (505) 294-1368 - Fx (505) 294-9958 - E-mail: narenas@nmdental.org *Print your name clearly as this will be the name that will appear on your ce confirmation and badge. **Be sure to submit individual emails. This will be the email your ce confirmation will go to. 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 Suite 601, Albuquerque, NM 87111 or FAX: (505) 294-9958 (PLEASE KEEP A COPY FOR YOUR RECORDS)
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