ISPD Spring Meeting - "Digital Radiology" Friday April 20, 2012 Doubletree Oakbrook Hotel 1909 Spring Road Oakbrook, IL 60523 Phone(630)472-6000 Registration Form - Please fill out and print from your computer Last Name First Name Dr Mr Ms Mailing Address 1 Mailing Address 2 City State Zip Please indicate your category Category ISPD Member/District IV Members @ $100 ISPD Affiliate Member @ $95 Non-Member Dentist/Physician @ $195 Student/Resident @ $25 Staff Member @ $50 Hours of Continuing Education Credit - TBD Make Checks Payable to: Illinois Society of Pediatric Dentists Please return this form with your check to: Dr. Melissa Vargas, Secretary/Treasurer Illinois Society of Pediatric Dentists Department of Pediatric Dentistry (MC 850) College of Dentistry 801 South Paulina Street Chicago, IL 60612 If you have any dietary restrictions/requirements, please list below Diet Requests

Illinois Society of Pediatric Dentists
M/C 850
801 South Paulina Street
Chicago, IL 60612
312/413-7714