PRE-REGISTRATION FORM

ALABAMA DENTAL HYGIENISTS’  ASSOCIATION

ANNUAL SESSION 2011

Name:      _________________________________________________

Address:  _________________________________________________

                 __________________________________________________

Phone:     _______________________________

E-Mail:   _______________________________

Friday, April 22, 2011           _________

Saturday, April 23, 2011         _________

Early Registration:                        $130.00 day      

                                                           $180.00 for the Weekend

Registration after April 27:             $165.00 day

                                                            $235.00  for the Weekend    

Amount Enclosed: _____________

Deadline to receive registration by mail is April 27.

Make checks payable to the Alabama Dental Hygienists' Association

Mail checks and registration form to:

Kim Williams

29126 Henderson Circle 

Madison, AL 35756