If you prefer to register off-line, you may print this form and fax in your registration to 888.634.2028.

1. First Name (required)
2. Last Name (required)
3. Title
   D.D.S.
   D.M.D
   (required)
4. Email (valid email required)
5. Office Phone (required)
6. Cell Phone (required)
7. Fax
8. Address (required)
9. City (required)
10. State/Province (required)
11. Zip/Postal Code (required)
12. Please Check All that Apply:
13. Enroll me in the 12-Session Hands-on Course for $14,400.00* plus two years of AGpO membership for $590.00*.
14. Sign me up for the Introductory Orthodontic Session for $150
15. I am interested in learning about:
16. Course Location
    Rockwall, TX
    (required)
17. Payments:
    Payments are not processed immediately. They will be processed within seven days of the Get Acquainted or Bonus session.
18. Please make my payment online
19. Amount $:
20. Card Type
21. Visa
    Mastercard
    Discover
    American Express
22. Credit Card Number:
23. Expiration Date:
24. Name as it appears on card:
25. Card Billing Address: (If different than above)
26. Address:
27. City
28. State
29. Country
30. Zip/Postal Code
31. No-Interest financing through the Academy (see payment options for details)
32. Finance through North Dallas Bank and Trust (upon approved credit, see payment options for details)
33. I will call Academy of Gp Orthodontics to arrange payment (Phone: 800.634.2027)
34. Cancellation Policy (required)
35. Cancellation Policy:I understand that once my tuition is paid, I have three business days to cancel the course without penalty. No refunds will be made less than 21 days prior to the first session. The Academy reserves the right to delay or cancel this course with my option of a full refund.
36. How did you hear about us?
37. Direct Mail
    AGpO Member
    Website
    Ad
    other
38. I heard about AGpO from:
39. Security Code: