EmailMe Form - 2023 NBC Qualified Course Provider Registration

I. Course Provider Information

Organization *

Contact Name *

Prefix First Last Suffix

Organization Address *

Street Address City State / Province / Region Postal / Zip Code

Contact Email *

Phone *

### - ### - ####

II. Payment Information

2023 Qualified Course Provider Registration Fee *

$1,750.00 - for NADL member organizations

$3,500.00 - for Non-NADL member organizations

Limited time discount: A $200.00 discount will apply to all registrations submitted on or before 11/15/2022.

Please note that all discounts will be applied by NBC administrative staff after this registration form is submitted.

Credit Card Type *

Visa

Mastercard

American Express

Please only select one.

Credit Card *

Name on Card *

First Last

Billing Address *

Street Address City State / Province / Region Postal / Zip Code

Email Receipt? *

Yes

No

III. Course Provider Signature

By submitting this registration form, you are acknowledging that Certified Dental Technicians (CDT) and Recognized Graduates (RG) will be eligible to receive continuing education credits for attending NBC approved courses.

It is your responsibility to provide attendees with NBC certificates of attendance, which will be emailed to you with your course approval information.

It is your responsibility to ensure that electronic submission of credits is completed no later than 15 business days after the course using the NBC CE Reporting Sheet, which will be emailed to you with your course approval information.

I certify by my signature that I understand the responsibilities of the 2023 NBC Qualified Course Provider and agree to adhere to this information. Additionally, I verify that the information supplied herein is true and complete to the best of my knowledge.

Signature *

Clear

Print Name *

Date *

MM / DD / YYYY