Tuition:

$3900 per course for courses starting after October 1, 2008

Please register me for the following course:  

Select Date
     
 
January 22-24, 2009
May 14-16, 2009
   
 

 

September 17-19, 2009
   
 

 

February 5-7, 2009

March 12-14, 2009
 

 
 

 

November 5-7, 2009
 

 

I learned about this course by:

My Specialty is:

 

First Name

Last Name

Organization

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Street Address (cont.)

City

State / Province

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Fax

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Card Holder Name Card Type  
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3 Digit Code

Exp.
Billing Address

Tuition includes technical training manual, professional information packets, research articles, special product discounts and certificate of completion.  Also included is a continental breakfast each day, lunch on Thursday and Friday and dinner for you and a guest on Friday evening.

Please charge the credit card provided.

Total Payment
$1000 deposit (required at registration the balance payable at least 21 days prior to the course)
I am sending a check today. (Please make checks payable to Pikos Implant Institute)
Registration will not be confirmed until check is received.
 

Cancellations must be made in writing at least 30 days prior to the course to receive a refund;
otherwise the $1000 deposit will be forfeited. A $100 administrative fee will be charged
for each change made within 30 days of the course.
 
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(Submission of this form does not guarantee registration for the course requested)