Registration and Housing Form

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1 Registration Fees ADA Member Dentists and Dental Students ADA Nonmember Dentists and ASDA Nonmember Dental Students Dental Team By Sept. 5, After Sept. 5, 5 p.m. CDT 5 p.m. CDT ADA Member Dentist $90 $180 ADA Retired Member Dentist $35 $70 ADA Retired Life Member Dentist $0 $25 Graduate Student, ADA Member $0 $25 Dental Student, ASDA Member $0 $0 ADA Nonmember Dentist or Graduate Student, Special One-Time Discount* $375 $750 ADA Nonmember Dentist or Grad Student $800 $1,600 ASDA Nonmember Student $0 $0 Dental Assistant $50 $100 Dental Assistant Student $0 $25 Dental Business Assistant $50 $100 Dental Hygienist $50 $100 Dental Hygienist Student $0 $25 Laboratory Technician $50 $100 All courses are ticketed, including courses with no fee required. You must register for all courses you wish to attend. Register online for up-to-date information on which courses still have space available. If you register using this form, your confirmation will indicate if a course is sold out. TO REGISTER FOR COURSES: Indicate the course code and fee for each time slot. Complete course listings are online and in the Preliminary Program. Only one ticket per time slot is permitted. If more than one course per time slot is listed, the first entry will be chosen. Write the total dollar amount on the Step 2 Subtotal or Step 3 Subtotal line. Guests International Dentists and Students Allied Health Professional $65 $130 Alliance of the ADA $40 $80 Component Staff $40 $80 Constituent Staff $40 $80 Dental Dealer (Exhibit Only) $65 $130 Friends and Family $40 $80 Guest $40 $80 Children (under 18 years) $0 $0 ADA Affiliate Member $90 $180 Affiliate Member, Online Membership Developed Affiliate Member, Online Membership Underserved $165 $255 $102 $192 REGISTER ONLINE The easiest way to register! ADA.org/meeting OR SUBMIT THE COMPLETED FORM TO EXPERIENT (ADA s official registration and housing company) TOLL-FREE FAX, U.S. ONLY or MAIL Experient/ADA Annual Meeting 5202 Presidents Ct., Suite 310 Frederick, MD Non ADA Affiliate Member Dentist $300 $600 Undergraduate Student $50 $100 Questions? Call Experient at (U.S. only) or *Special One-Time Discount. The ADA is offering a one-time opportunity for U.S. nonmembers to join us the U.S. nonmember registration fee has been reduced from $800 to $375! Come to the ADA annual meeting and experience the benefits of belonging to the premier organization representing the dental profession. U.S. nonmembers who have previously taken advantage of this offer are not eligible for this reduced rate. ALL REGISTRATION AND CE COURSE TICKET FEES INCREASE AFTER SEPT. 5. REGISTER EARLY!

2 If registering more than one professional, please use a separate form. Please have a photo I.D. and membership card ready on-site. Primary Registrant Information ADA/ASDA Member Number Group Code: PFASAT A membership number must be provided to be eligible for member rate. The group code is required to obtain a reservation in your organizations designated room block. SOURCE CODE: AG First Time Attendee (Check this box if this is the first time you will attend an ADA annual meeting.) Company Address City State Zip Country Phone Fax Home Office SUBTOTAL 1 Continuing Education Program Course Code Quantity Fee Course Code Quantity Fee Course Code Quantity Fee Distinguished Speaker Series Quantity Fee Total Special Event Fees SUBTOTAL 2 SUBTOTAL 3 Event Date Code Quantity Fee Total Welcome Celebration Thursday, Oct. 9 6:30-9:30 p.m. ADA Foundation Give Kids A Smile Gala $100 of each ticket will be a tax-deductible Friday, Oct :30 p.m. E000 charitable contribution to the ADA Foundation. New Dentist Reception Friday, Oct. 10 5:30-7:30 p.m. E001 ADAA President s Reception Saturday, Oct. 11 5:30-7 p.m. E002 International Office Tour Friday, Oct. 10 E003 E004A Adult E004B Children Summary of Fees SUBTOTAL 4 Primary Registrant Fees SUBTOTAL 1 Primary Registrant Continuing Education Fees SUBTOTAL 2 Distinguished Speaker Series SUBTOTAL 3 Special Event Fees SUBTOTAL 4 TOTAL 1

3 Additional Registrants Additional Registrant 1 Code Quantity Fee Code Quantity Fee Code Quantity Fee Distinguished Speaker Series SUBTOTAL 1 Additional Registrant 2 Code Quantity Fee Code Quantity Fee Code Quantity Fee Distinguished Speaker Series SUBTOTAL 2 Additional Registrant 3 Code Quantity Fee Code Quantity Fee Code Quantity Fee Distinguished Speaker Series SUBTOTAL 3 FOR MORE INFORMATION ABOUT ADA 2014, VISIT ADA.org/meeting Summary of Fees Additional Registrant 1 SUBTOTAL 1 Additional Registrant 2 SUBTOTAL 2 Additional Registrant 3 SUBTOTAL 3 TOTAL 2

4 San Antonio Hotel Choices 1st Choice 2nd Choice 3rd Choice 4th Choice If hotel choices are not available: Please reserve a room at a comparable hotel. Do not reserve a room. The choice should be based on: Rate Location Reservations Payment Information Summary of Fees Primary Registrant Fees Total 1 Additional Registrants Fees Total 2 GRAND TOTAL Payment Method: Check/Money Order Visa MasterCard American Express Credit Card Number Expiration Date Name (as it appears on card) Signature I hereby authorize Experient to debit my credit card account with the Grand Total due. I also consent to debiting or crediting my account with the amount of any subsequent change(s) to the items booked. If your credit card is declined, your registration, housing and course choices will not be processed. Your registration data may be used for a variety of purposes, including membership recruitment, future annual meeting announcements and commercial purposes approved by the ADA.

5 San Antonio Hotel Locator 46 /Market Area 23 8 N Surrounding Area TO NEW BRAUNFELS & SAN MARCOS ATTRACTIONS Visit ADA.org/meeting for additional information. G ON Z AL E S - N I

6 /Market Area Hotel Name Candlewood Suites Courtyard Market S. Laredo St. $110 Y Santa Rosa S. $152 Y 18 Courtyard Riverwalk N. St Mary's St. $185 Y 4 Crockett Hotel Bonham St. $159 Y 4 Doubletree Market Drury Inn & Suites Riverwalk Map Code Address W. Cesar E. Chavez Blvd. Rates ADA Shuttle $195 Y N. St. Mary's St. $179 Y 5 Walking Distance to Convention Center /Market Area Hotel Name Omni La Mansión del Rio College St. $289 Del $319 River Y 4 Red Roof Inn E. Houston St. $80 Y 4 Residence Inn Alamo Plaza Residence Inn Market Riverwalk Suites Map Code Address Bonham $185 Y S. Santa Rosa Blvd. $149 Y S. St. Mary's St. $139 Y 2 Sheraton Gunter E. Houston St. $189 Y 5 Rates ADA Shuttle Walking Distance to Convention Center Drury Plaza Riverwalk S. St. Mary's St. $179 Y 4 El Tropicano Riverwalk Lexington Ave. $160 Y 8 Embassy Suites Riverwalk E. Houston St. $215 Y 6 Emily Morgan Hotel E. Houston St. $218 Y 4 Fairfield Inn & Suites Alamo Plaza Fairfield Inn & Suites Market Bonham $119 Y S. Santa Rosa $139 Y 17 Grand Hyatt E. Market St. $250 N 1 blk Hampton Inn, Riverwalk Area Bowie St. $135 Y 4 Hilton Palacio del Rio S. Alamo St. $250 N 2 SpringHill Suites Alamo Plaza Bowie St. $129 Y 4 St. Anthony Hotel E. Travis St. $189 Y 5 Staybridge Suites Sunset Station TownePlace Suites Hoefgen Ave. $140 Y E. Houston St. $169 Y 4 Westin Riverwalk W. Market St. $246 City $266 River $299 Ste $369 Corner Ste Wyndham Garden Riverwalk/Museum Reach Y th St. $159 Y 4 Holiday Inn Express Market Area Holiday Inn Express No. Riverwalk El Paso $99 Y Camaron St. $109 Y 6 Wyndham Riverwalk Pecan Street E. $185 Y 7 Holiday Inn Express Rivercenter Holiday Inn Market E. Commerce St. $159 Y W. Cesar E. Chavez Blvd. $109 Y 18 Holiday Inn Riverwalk N. St. Mary's St. $179 Y 4 Home2 Suites Riverwalk Navarro $149 Y 4 Homewood Suites Riverwalk/ West Market Street $235 Y 4 Surrounding Area Hilton San Antonio Airport JW Marriott Hill Country Resort La Cantera Hill Country Resort NW Loop 410 $139 Y 10 mi Resort Pkwy. $290 N 25 mi La Cantera Pkwy $205 N 20 mi Marriott Northwest NW Loop 410 $119 N 11 mi Hotel Contessa W. Market St. $236 Y 5 Hotel Indigo Riverwalk N. St. Mary's St. $149 Y 8 Hotel Indigo, at the Alamo N. Alamo St. $141 Y 4 Hotel Valencia Riverwalk E. Houston St. $269 Y 5 Hyatt Place Riverwalk S. St Mary's St. $181 Y 4 Hyatt Regency Losoya St. $235 Y 4 LaQuinta Inn & Suites La Quinta Inn & Suites Riverwalk W. Cesar E. Chavez Blvd Blum $159 Std $189 Ste $145 Y 8 N 3 Marriott Plaza S. Alamo St. $209 N 1 blk Marriott Rivercenter (HQ) Not available for general attendees. Marriott Riverwalk (HQ) Not available for general attendees Bowie St. $275 Std $315 Club East Market St. $275 Std $300 River N 1 blk N 1 blk Menger Hotel Alamo Plaza $156 Y 3 Hotel listing and rates are accurate as of March 15, For current listing, please visit ADA.org/meeting. Triple Points for Booking at ADA Official Hotels Use your ADA Signature Visa card when you book at any of the ADA official hotels for ADA 2014 and receive triple rewards points 1. The ADA Signature Visa Card, issued by U.S. Bank, has one of the most robust rewards points programs, and it was developed just for dentists. Call ext or visit usbank.com/adavisacard to apply. 1 Bonus points will be calculated based on occupancy at one of the ADA official hotels between October 2, 2014, and October 21, 2014, in the San Antonio, Texas metropolitan area. Bonus points will be applied by December 31, Account must be open and current to earn rewards and redeem points. Reward points are based on net purchases. Net purchases are purchases minus credits and returns. The creditor and issuer of the ADA Visa Card is U.S. Bank National Association, pursuant to a license from Visa U.S.A. Inc. Mokara Hotel & Spa W. Crockett St. $340 Y 4

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