Registration Form 2024-2025

Registration Form for 2024-2025 Class

The Puerto Rico MaxiCourse® Program and Clinical Residency in Implant Dentistry
NAME
Degree
License No
AGD
State
AAID
Mailing Address
Email
example@example.com
Phone Numbers: Office Cellular
Office
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Cellular
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Home
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Total cost of tuition: $27,950.00

* Payments in Full have a 7% discount (does not apply to payments with a credit card)

Deposit: $2,000 (non-refundable) Payment: Money Order:
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