NEW YORK MARRIOTT MARQUIS1535 BROADWAY

NEW YORK, NY 10036

For more information contact the ICOI Central O�ce at

(973) 783-6300 or visit our website at www.icoi.org

NEW YORK,NEW YORKNEW YORK,NEW YORKAUGUST 15-17, 2019

– ICOI WORLD CONGRESS –

XXXVII

ICOI is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from April 1, 2018 - March 31, 2021. Provider ID# 217378.

What Really

Matters Today

ICOI is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at www.agd.org/cerp.

TOTAL AMOUNT USD: $___________________________

Credit Card: Complete information below and

Pre-Congress Courses: Thursday, August 15, 2019

August 15 – 17, 2019 • New York Marriott Marquis

R E G I S T R A T I O N F O R M

ICOI ID# Family Name (Surname) - Please print or type First Name - Please print or type

Street Address

City State/Province Zip Code Country

Phone E-Mail

On/Before After June 15, 2019 June 15, 2019

Practitioner: ❒ $775 ❒ $875 ICOI Member ❒ $925 ❒ $1025 Non-Member

Laboratory Technician: ❒ $350 ❒ $380 ICOI Member ❒ $450 ❒ $480 Non-Member

Full-Time Faculty: ❒ $375 ❒ $410 ICOI Member(must submit faculty credentials with registration) ❒ $475 ❒ $505 Non-Member

Full-Time Student: ❒ $250 ❒ $300 ICOI Member(must submit full-time status with registration) ❒ $350 ❒ $400 Non-Member

METHOD OF PAYMENT

Cancellation Policy:50% of registration fee will be refunded if requested on or before July1, 2019. Cancellations after this date are non-refundable. Anyone requesting a refund must complete a Refund Request Form. Please contact thecentral office via email at icoi@dentalimplants.com.

THREE WAYS TO REGISTER:1. Online at www.icoi.org2.

fax to (973) 783-1175

3. Mail (make checks payable in US funds to ICOI):

55 Lane Road, Suite 305

Fairfield, New Jersey 07004

phone: (973) 783-6300

CREDIT CARD:

❒ MasterCard ❒ Visa ❒ American Express

Credit Card Number:

__ __ __ __ –__ __ __ __ –__ __ __ __–__ __ __ __

Billing Zip Code: ______________ CVV No: ______________

Exp. Date: ________ /_________ month year

Registration includes scientific session only. It does not include Auxiliary Session, Accompanying Persons, Gala Dinner, Award Ceremony or Pre-Congress Courses.

REGISTRATION FEES SCIENTIFIC SESSION

* All on-site payments must be made by credit card or in cash (USD)

ICOI WORLD CONGRESS XXXVII • NEW YORK, NY

HOTEL INFORMATIONThe New York Marriott Marquis is the host hotel for this event. Discounted room rate is $295 until July 10, 2019. For reservations please call: (212) 398-1900.

Be sure to mention “ICOI” when making your hotel reservation to get the discounted rate.

ACCOMPANYING PERSONS:$150 USD per person (admittance to scientific session not included)

$

____________________________________________

AUXILIARY SESSION: ❒ ADIA Member: $295 ❒ ADIA Non-Member: $395

❒ Dental Hygiene ❒ Practice Management❒ Dental Assisting ❒ Implant Coordinator

Please Choose One:

Name

AWARD CEREMONY: Friday, August 16, 2019

Award Being Received: ❒ Fellowship ❒ Mastership ❒ Diplomate

PRE-CONGRESS COURSES: Thursday, August 15, 2019

__________ Number of people attending at $150 USD per person

GALA DINNER: Friday, August 16, 2019

$ ______________________......

❒ Dr. Yahav (Augma): Gratis ❒ Dr. Resnik (Glidewell): $99 ❒ Dr. Simonpieri (Biotech): $200

❒ Dr. Panjali (Dental Implant Technologies): Gratis ❒ Drs. Kosinski and Miller (Impladent): Gratis

❒ Dr. Russo (Salvin): $225 ❒ Gary Kadi (NextLevel Practice): Gratis