PA Study Club Registration Register for the 2017-2018 Program Members Name: * Contact Person: * Contact Person in Your Office Address: Phone Number: * FAX Number: * Email Address: * Website: Would you like your name, address and phone number listed on the Periodontal Associates website? YesNo Would you like your email address and/or website listed and linked on the Periodontal Associates website? YesNo Tuition Fee: $1950 Visa and MasterCard are accepted. If you prefer to pay by cheque, please make cheque payable to “PA STUDY CLUB”. $975 payable by September 1st, 2017$975 payable by January 1st, 2018 PLEASE INDICATE IF YOU ARE USING THE SPLIT PAYMENT OPTION. YesNo Registration forms should be mailed to: PA STUDY CLUB - 4295 VILLAGE CENTRE COURT, MISSISSAUGA, L4Z 1S2 OR FAXED TO (905) 279-9806. A receipt will be issued each time payment is made. As registration is limited, we require your completed registration returned to us by July 28, 2017. (YOUR PAYMENT WILL NOT BE PROCESSED UNTIL SEPTEMBER 1ST, 2017.