November In Person Wine Tasting CE
Fill out the form carefully for registration
Name (as it appears on your license)
First Name
Middle Name
Last Name
E-mail
example@example.com
E-mail confirmation
example@example.com
License number (n/a if you do not have a license number); and Phone Number
License types
RDH
RDHAP
RDA/RDAEF
DDS
Student
Other
Membership Status (membership status will be verified)
Potential Member (Non-members of CDHA/DDS/RDA/RDAEF/Other)
CDHA members
CDHA Student members
CDHA Student potential-members
My Products
*
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Potential Member
Non-Members/DDS/RDA/RDAEF/Other
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
CDHA Member
Members. Membership will be verified
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
CDHA Student Member
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
CDHA Student Potential-member
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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