Tuition and Registration Form 2017-2018
*Please Copy, Paste and Print*
Tuition is $250. Please make checks payable to the Pittsburgh Dental Hygiene Network. Membership is limited!
Tuition is due by September 15, 2017 (Tuition is non-refundable)
Mail payment and registration to:
Pittsburgh Dental Hygiene Network
c/o Mark Weingarden, DMD
Sam Bakuri, DMD, MSD
4290 William Flynn Highway
Suite 104
Allison Park, PA 15101
Name_________________________________________
Office Name ____________________________________
Office Phone Number ______________________________
Home Phone Number ______________________________
Cell Number ____________________________________
E-mail ________________________________________
(email is critical for member communication)
Address to mail CE certificates:
__________________________________
__________________________________
__________________________________
Register by September 15 th, 2017 to reserve your spot.
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