Dr. Raymond Bertolotti - Seminar Registration Form

|| Go Back to Adhesion Dentistry's main page || Review the Schedule of International Seminars ||

Dr. Raymond Bertolotti - Adhesion Dentistry

Dr. Raymond Bertolotti - Seminar Registration Form
And Complimentary Newsletter Offer. You can also print out this form and fax it to the number below.

For Your Efforts...

Be sure to fill out the form completely and press, Send My Registration, at the bottom to get in touch with us and receive a free issue of our newsletter.

Please fill in the following completely; don't forget to select the date and location of the seminar you wish to attend. From this form we will have the necessary information but you are not considered "registered" until we receive your tuition. Upon receipt of tuition, we will send a confirmation by FAX or mail. Included will be hotel information and when appropriate, travel information.

A ComplimentaryNewsletter

As a service to those who attend our seminars, we mail a complimentary newsletter to those who have attended in the last 5 years. The newsletter is intended as a continual update. We are now making it available here on the Internet for all interested persons. The newsletter is not available by subscription but we will be pleased to send a complimentary issue or two to those who just provide us with your name and mailing address on the form below. Ignore the desired date and location if you are requesting the newsletter only. We have no set dates for the issues. Our intention is to provide more frequent updates on the Web. Your suggestions are welcomed.

Name:

E-mail address:

Address1:

Address2:

City: State: , Zip:

Country:

Telephone:

Fax:

Desired date and location:

Tuition: Except Yosemite, the tuition is US$ 275. for the first person. Additional persons (dentists and non-dentists) are $175. when registering at the same time as the first person. Registration at the door, add $20. per person. Yosemite (14 hours CEU) is $450. per person attending the seminar program. Checks are preferred. (Refunds for tuition paid by credit card are subject to deduction of our banking costs.) We suggest that non-US residents pay tuition by VISA or Mastercard for easy foreign exchange. Call us at 510-483-2411 or FAX your registration to 510-652-8729.

I wish to bring other(s) attending.

Name/Title:

Name/Title:

Please select a payment option

I will mail mail my check to the following address.

Fifth Quarter Seminars, 345 Estudillo Ave, Ste 102, San Leandro, CA 94577

I will fax my Visa/MasterCard number, expiration date, security code, and ZIP code for card to:

(510) 652-8729
a secure, private line

Upon receipt of tuition, we will send a confirmation by FAX or mail.

Note: Once you hit send, the message has been sent. Sometimes it doesn't clear the form, but we will receive it.

A Bonus for You, Complimentary Issues of Our Newsletter

Click here to read the two most current editions of our newsletter.

Thank you for taking the time to fill out this registration form.

Go to the top of the page

More About Dr. Bertolotti & Contact Info, (click here).

Fifth Quarter Seminars
425 Estudillo Avenue, San Leandro, CA 94577

FAX: (510) 652-8729 Phone: (510) 483-2411 E-mail: rbertolott@aol.com