Full Name __________________________________________________

Nickname or Preferred Name
     for nametag____________________________________________

Street______________________________________________________

City  ______________________________________________________

State ____________________________Zip Code__________________

Guest(s)____________________________________________________

        ____________________________________________________

        ____________________________________________________

Phone Numbers:

Office  ___________________________ Home ___________________

Fax:    ___________________________

REGISTRATION FEE:

Member of College of Diplomates      $475 __________________

Spouse/Adult Guest of College Member $375 __________________

Diplomate Non-Member of the College of Diplomates
(includes $50 annual dues)           $525 __________________

Spouse/Adult Guest of Diplomate Non-member of the College

                                     $375 __________________

Children of Registrant               $250 x____=____________

American Board of Endodontics candidate who is a guest of a mentor Member of the College
                                     $475 __________________

                   TOTAL REGISTRATION $_____________________

Mail this form and a check for the full amount of the Total Registration (payable to the College of Diplomates) in the enclosed envelope to:

Susan Hawkinson, Administrative Secretary
College of Diplomates
P.O. Box 2673
Glen Ellyn, Il. 60138-2673

Should you have any questions contact:

Dr. Fredric Goodman
301 East 75th Street
New York, NY 10021
Phone: 212/249-5809

Cancellations must be in writing and received by June 23rd, 2002.
Cancellations will not be accepted after that date.