RADIOGRAPHICS ORDER FORM


Name of Person(s) Taking the Test: (As the name should appear on Certificate)
1.
*First Name:
*Last Name:
2.
First Name:
Last Name:
3.
First Name:
Last Name:
4.
First Name:
Last Name:
5.
First Name:
Last Name:
6.
First Name:
Last Name:
7.
First Name:
Last Name:
8.
First Name:
Last Name:
         
Employed by Sponsoring Dentist or DR.
Contact Person Name:
 
Dentist's Office or School/Academy Mailing Address for Certificates:
 
Dentist or School/Academy Name:
   
*Address:
*City:
*State:
*Zip:
*Phone Number:
Fax:
*Email Address:
   
       
Please Choose Format: DVD CD-ROM

Fee: Member Dentist $50.00 (For 1st staff person):
(Fee includes depreciation cost on video, one student's workbook, certificate of completion, and mailing charges.)
   
Fee: Non-Member Dentist $85.00 (For 1st staff person):
PLUS: $300.00 Deposit for course:
(refunded upon return of DVD/CD-ROM)
Total Initial fee: $385.00
   
For additional staff, please add the following:
 
(Member Dentist) Additional workbook for added staff person:
(Non-Member Dentist) Additional workbook for added staff person:

Add $15 credit card convenience fee*
Total amount of fees due to the LDA =
(Please enter your total)

I will pay by: Check or Credit Card*

If paying by check, please mail to:
Louisiana Dental Association
7833 Office Park Blvd.
Baton Rouge, LA 70809


If paying by credit card,
please enter the information below:

Paying with: VISA Master Card
Card Number:
Expiration Date:
Name as it appears on card:
3 digit security code on back of card:

Questions or Comments:






Note: The DVD/CD-ROM must be returned to the LDA office within (15) working days. If it is past the designated due date, there will be an assessment of $3.00 per day. If it is not returned within thirty (30) days from the due date, you will be assessed $100.00, plus shipping and handling for replacement.

Return to: Louisiana Dental Association, 7833 Office Park Blvd., Baton Rouge, LA 70809


*In accordance with a resolution of the LDA Board of Directors, beginning August 1, 2009, card users will be assessed a separate, non-refundable convenience fee of $15 at the time of each credit or debit card payment made to the Louisiana Dental Association (LDA). The non-refundable convenience fee will be included with your total payment amount on your credit card statement.

Automated Clearing House (ACH) payments, better known as automatic withdrawals for dues, from checking and savings accounts will continue to be accepted by the LDA via the ACH Network without a convenience fee. The LDA will also continue to accept check payments via mail or in person without a convenience fee.

The LDA accepts Visa and MasterCard.