SIX ELEMENTS™ COURSE REGISTRATION FORM

2.5-Day Andrews Foundation Course
   

REGISTRATION FORM


COURSE DATES

___ August 27-29, 2009            2.5-Day Course                        Pittsburgh, Pennsylvania
___ October 8-10, 2009            2.5-Day Course                        San Diego, California

 

Tuition:  $300 for residents enrolled in a 2 or 3 year ADA accredited U.S. or Canadian orthodontic or oral and maxillofacial surgery program, and full-time faculty.  Tuition is due upon registration.  To enroll, please fill out and return the registration form page (or a copy), mark your calendar, and make hotel and travel arrangements.

PREREQUISITES:
Prerequisites:   Must be an orthodontist or oral and maxillofacial surgeon, or currently enrolled in an ADA accredited program.

Payment:  Please send payment (by check in U.S. Funds payable on a U.S. Bank only, or use your Visa or Mastercard) to:

The Andrews Foundation            Tel. (800) 799-8952 (in USA only), (619) 224-0866           
2025 Chatsworth Blvd.               Fax.  (619) 224-6979  E-Mail:   lfandrews@aol.com
San Diego, CA  92107                Website: www.andrewsfoundation.org

_____Visa _____Mastercard. Acct. #________________________ Exp. date ______

Amount Enclosed $_____________________ Telephone no. (____)______________

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Name (Please Print)                        Dental School                                          Yr. of Grad.

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Signature                                         Orthodontic School                                 Yr. of Grad.

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Address

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City                                                                              State Zip (Postal) Code

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Country

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Fax. no.                                                                                  E-mail address

___ I would like to include the price of the textbook “Straight Wire, The Concept and Appliance”.  The price of the book is $125.00(US) plus shipping and handling ($20 U.S., $40 Outside Continental U.S.). California Residents please add $8.75% sales tax ($10.94)

Cancellation Policy:  The Andrews Foundation reserves the right to cancel or postpone any course due to unforeseen circumstances or insufficient enrollment.  In the event of such cancellation, full tuition will be refunded.  For enrollees, there will be a full refund (less a $100 administration fee) for cancellations six weeks prior to the course; there will be no refund or credit given if cancellation is less than six weeks prior to the course unless enrollee can locate a qualified replacement or the vacated spot can be filled from a course waiting list.  The Andrews Foundation assumes no responsibility for transportation or lodging.