Dentist's name_____________________________________________________License #________________________________
Address____________________________________________________________Email____________________________________ City_______________________________State_______________Zip__________Phone________________________ Credit card#_______________________________Expiration date_____________Code________Billing zip code_________ Staff member name______________________________________________License #___________________ Email completed registration form with payment information to fmds@fmds.com or fax to 559 438-7287 You may register by phone as well 559 438-7284 In order to record attendance for the CA Dental Board, each attendee is required to register and sign in with a unique email address. |