PRE-REGISTRATION FORM

ALABAMA DENTAL HYGIENISTS’  ASSOCIATION

ANNUAL SESSION 2012

Name:      _________________________________________________

Address:  _________________________________________________

                 __________________________________________________

Phone:     _______________________________

E-Mail:   _______________________________

Friday, April 27, 2012   _____________

Saturday, April 28, 2012 ___________

Early Registration: Prior March 1              $139.00 per day

                                                                            $189.00 weekend

Registration after March 1                           $169.00 per day

                                                                            $219 weekend

Amount Enclosed  ________________

Make checks payable to the Alabama Dental Hygienists' Association

Mail checks and registration form to:

Kim Williams

29126 Henderson Circle 

Madison, AL 35756