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 #__________________