Haddad Seminar Registration

Back to Haddad Memorial Seminar

Date
03/17/2023 8:00am - 5:00pm (in person)

Registration Fees
Dentists: $250.00
Auxiliary Staff: $100.00
Former Residents and Attendings: $100.00
Former Residents and Attendings Auxiliary Staff: $50.00

* indicates required field

Attendees

Enter first and last names of each attendee; Include ADA# for each registrant for verification certificate:

First Name

Last Name

ADA #

Registration Type

Attendee 1

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 2

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 3

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 4

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 5

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 6

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 7

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 8

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 9

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 10

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 11

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 12

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 13

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 14

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 15

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 16

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 17

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 18

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 19

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Attendee 20

First Name

Last Name

ADA #

Registration Type

Dentists Auxiliary Staff Former Residents and Attendings Former Residents and Attendings Auxiliary Staff

Add Another Attendee

Contact Information

Prefix

First Name

Last Name

Phone Number

Email Address

Billing Address

Please note that, when paying by credit card, the participant address used for registration MUST match the address on record for the credit card being used.

Address

City

State

-- Select -- Alabama Alaska Alberta American Samoa Arizona Arkansas Australian Capitol Territory British Columbia California Canal Zone Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Foreign State Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Military - Americas Military - Europe Military - Pacific Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New South Wales New York Newfoundland Newfoundland and Labrador Norfolk Island North Carolina North Dakota Northern Mariana Islands Northern Territory Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Provence of Quebec Puerto Rico Quebec Queensland Rhode Island Saskatchewan South Australia South Carolina South Dakota Tasmania Tennessee Texas Utah Vermont Victoria Virgin Islands Virginia Washington West Virginia Western Australia Wisconsin Wyoming Yukon Territory

Zip Code

Country

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Payment

Total

Payment Type

Credit Card

First Name on Credit Card

Last Name on Credit Card

Credit Card Number

Expiration

01 - January 02 - February 03 - March 04 - April 05 - May 06 - June 07 - July 08 - August 09 - September 10 - October 11 - November 12 - December 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038

CVV2 / CVC2

3 or 4 digit code on back of card

How to find your CVV2

The CVV2 is a 3- or 4-digit value printed on the card or signature strip, but not encoded on the magnetic stripe.

• MasterCard, Visa and Discover credit and debit cards have a 3-digit code. It is not embossed like the card number, and is always the final group of numbers printed on the back signature panel of the card. New North American MasterCard and Visa cards feature the number in a separate panel to the right of the signature strip.
  
  
• American Express cards have a 4-digit code printed on the front side of the card above the number. It is printed flat, not embossed like the card number.

Close

My card has no CVV2 imprint

I authorize Utica University to charge my account the registration fees for this seminar to support the Dr. Michelle E. Haddad Scholarship Fund, the Dental Hygiene Scholarship Fund, the Dental Residency Program Education Fund, and the Dr. Thomas Hebert Memorial Scholarship. *