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Please complete the following form and fax it to 415-476-3448.
You may also mail the form with your payment to:
Educational Services
707 Parnassus Avenue, Room D-4010
San Francisco, CA 94143-0636
| Course Name : |
| Course Date : |
| Name : |
| Address : |
| City State Zip : |
| Day Telephone : ( ) |
California Dental Lic. No. : _____________________
License Type: (Please Circle One)
DDS, RDH, RDAEF, RDA, DA, CDT, Other _______________ |
If DDS, how would you describe your practice?
(Please Circle One)
GP Perio Ortho Prosth Endo Oral Surg Pedo |
Form of Payment:
(Please Circle One)
Check (made payable to UC REGENTS)
Credit Card (We accept MC/Visa/Amex.) |
Account Number:
Date Card Expires:
Signature: |
Please circle if you are a UCSF Alumnus
Program Year completed: _______
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