12 2024 Fiesta NMDA June 6–8, 2024 New Mexico Dental Association is an ADA CERP Recognized Provider June 6-8, 2024 | Crowne Plaza, Albuquerque Registration Form Register only once. If you register twice (i.e., online and via fax), you may be charged twice. PRIMARY REGISTRANT Name Badge name (if different) Address Registrant type Fee City Ticketed Event Code Fee State Zip Ticketed Event Code Fee Email Ticketed Event Code Fee Daytime Phone Ticketed Event Code Fee PAYMENT INFORMATION Total payment amount $ Check Ck number Check amount $ Make check payable to New Mexico Dental Association Credit Card O Visa O MC O AmEx Card amount $ Card number Exp Date Printed name on card Signature Registrant Type and Pricing Type Early Bird (ends May13) Regular (Starts May 14) A NMDA/ADA Member $245 $295 C Non-member $550 $595 D Hygienist $125 $150 E Dental Assistant $125 $150 F Technician $125 $150 G Business Staff $125 $150 I Public Health/Gov’t (non-member) $335 $385 J Guest (Non-dental spouse or child) Not eligible for CE credits $20 $25 K NMDA/ADA Retired Member $50 $50 L NMDA/ADA Life Member $0 $0 N Military Personnel $100 $115 S Student (not working) $20 $20 Ticketed Events Codes 1 Past President Breakfast (Thu) $35 8 Eat & Learn Breakfast (Fri) $35 2 FACD/FICD/PFA Lunch (Thu) $35 9 Radiography Certification Workshop – Dental Assistants (all day Fri) $195 3 Laser Treatment Workshop (Thu) $125 4 Fiesta Lunch (Thu) $35 10 Keynote Lunch (Fri) $45 5 Digital Dentures Workshop (Thu) $95 11 CPR/BLS (Fri) $70 6 CPR/BLS (Thu) $70 12 Casa Rondeña Wine Tour (Fri) $99 7 Mystery Dinner Theater (Thu) $75
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