Membership Application Form

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. Country (required)
12. Zip/Postal Code (required)
13. School Graduated (required)
14. Year Graduated (required)
15. Presently doing orthodontics?
    Yes
    No
    (required)
16. What techniques do you use?
17. Is it ok to notify you of future courses?:
    Yes
    No
    
18. Please make my payment online
19. Courses you are interested in attending:
20. Topics you are interested in learning about:
21. $295.00
22. Card Type
23. Visa
    Mastercard
    Discover
    American Express
24. Credit Card Number
25. Expiration Date:
26. Name as it appears on card:
27. Card Billing Address: (If different than above)
28. Address:
29. City
30. State
31. Country
32. Zip/Postal Code
33. I will call Academy of Gp Orthodontics to arrange payment (Phone: 800.634.2027)
34. Security Code: