Date* Complete the form below to register for UB's Dental Hygiene Anesthesia Course. 3 Day Course Fee: $1,100.00 (+$100 late fee, if registered after October 10) 20% discount for current students: $880.00 (+$80 late fee, if registered after October 10) Fee includes light breakfast and lunch on full days and light breakfast on half day, course manual, and clinic supplies. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone Number*Email* Are you a current UB student?*No, I am not a current UB student (Rate for Dental Hygiene Anesthesia course: $1,100)Yes, I am a current UB student (Rate Dental Hygiene Anesthesia Course: $880)Are you a current UB student?*No, I am not a current UB student (Rate for Dental Hygiene Anesthesia course: $1,200)Yes, I am a current UB student (Rate for Dental Hygiene Anesthesia Course: $960)Total $0.00 Upload Your DocumentsPlease submit a copy of your dental hygiene license, CPR card, malpractice insurance and hepatitis documentation. If you do not have your documents available for upload at this time, you may submit them via email to Eileen Herlihy-Santiago, Coordinator, Postgraduate Education Department, firstname.lastname@example.org. Documents must be submitted at least one week before start of course. Drop files here or Accepted file types: pdf. Where did you hear about the training program?*Internet AdvertisingFriend or ColleagueRadioMagazine/NewspaperOther Class size is limited. Full payment is expected upon registration and is non-refundable. Confirmation* By clicking the Checkout button below, you will be registered and taken to the checkout page to enter your payment information.