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Didier Dietschi Registration Form

 
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Didier Dietschi Registration Form

 

Registration for Dr Didier Dietschi – Friday 12 March 2010

Full Name: *
Practice:
Postal Address:
City:
Country:
Phone Work: *
Mobile:
Email: *
My role is:
*
  Required*
 
I am an existing NZACD Member
Yes     No
   
I would like to become a member
Yes     No
$365 (annual)  
Registration Rates: NZACD Member
Non-Member
Technician/Hygenist
Staff

$595
$695
$195
$95

 
Select your rate:
(If you ticked Yes to becoming a Member now, select Member rates)
   
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