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2018 Qualified CE Provider Registration
Qualified Course Providers can receive up to 200 course approvals during the 2018 calendar year for a registration fee.
Being a NBC-approved qualified continuing education provider allows your organization the experience and benefits of a streamlined crediting process for attendees. All NBC-approved courses are listed online on The Foundation for Dental Technology’s website. This website receives over 14,000 hits per month.
I. Provider Information
Name
*
Prefix
First
Last
Suffix
Organization
*
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Email
*
Phone
*
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-
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-
####
Fax
###
-
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-
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II. Payment Information
Registration fee of $3,250 annually (50% discount to NADL members in good standing = $1625 annually)
Select Registration Type
*
NADL Member
Non-Member
Credit Card Type
*
Visa
Mastercard
American Express
Please only select one.
Credit Card Number
*
Expiration Date
*
MM
/
YY
Sec Code
*
Sec Code: Is the 3 digit number on the reverse side of your credit card. For Amex cards only, this is the 4 digit number on the front of your card
Name on Card
*
First
Last
Billing Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Email Receipt?
*
Yes
No
III. Signature
I certify by my signature that I understand the responsibilities of the Sponsor 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
Total
$0.00
