2012 Wednesday Dinner Dance

Subcommittee Host/Volunteer Form (Test)

The New York County Dental Society and the Second District Dental Society are proud sponsors of the Greater New York Dental Meeting, the Largest Dental Meeting/Exhibition/Congress in the United States.

Please show your support by volunteering to be an On-site Host/ Volunteer for our Meeting. This is open to all interested applicants and is a way to help us produce the excellence for which we are known.

Please Fill In Completely

(* Fields Are Required)
Today's Date: (mm/dd/yyyy)	* A (mm/dd/yyyy) date is required.Invalid format.
Title:	* Dr. Mr. Mrs. Ms. Prof. Please select your title.
First Name:	* Your first name is required.
Last Name:	* Your last name is required.
Professional Degrees:	* A value is required.
Office Address:	* Your office address is required.
Address 2:
City:	* A value is required.
State:	* A value is required.
Zipcode:	* A value is required.Invalid format. +
Office Phone:	* A value is required.Invalid format.  Please enter numbers only
Mobile Phone:	* A value is required.Invalid format.  Please enter numbers only
Fax Phone:	* A value is required.Invalid format.  Please enter numbers only
E-mail address:	* An email address is required.Invalid format.
Specialty	* Please make a selection. Dentist Hygenist Assistant Technician Administrative Staff Dental Student
Member of What Society?	N.Y. County Dental Society Second District Dental Society Other Please select an item.
I speak A value is required I am WILLING to assist international guests. I am NOT willing to assist international guests. Please make a selection.

*Committee Choices:
(Please number your choices (1,2,3 & 4 ) in the order of your preferences. First come first served for appointments)
A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.	Entertainment
A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.	Essays_Scientific_Poster_Sessions
A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.	Registration
A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.The entered value is less than the minimum required.The entered value is greater than the maximum allowed.	Seminars/Workshops

Session Selection: *	Saturday	Sunday	Monday	Tuesday	Wednesday
(Minimum of 2)	AM	AM	AM	AM	AM
	PM	PM	PM	PM	PM

Enter the secure code here: * The secure code is required.Invalid format.