Annual Shred-It & E-Waste Event Registration 4 5 Annual Shred-It Event Registration What is your membership type?(Required) TCDS Member CDA Member (not TCDS) Non-Member Dentist Name(Required) First Last Email(Required) Phone(Required)License #(Required)ADA#(Required)Local Society(Required)This field is hidden when viewing the formTCDS Member PriceThis field is hidden when viewing the formCDA PriceThis field is hidden when viewing the formNon-Member PriceTotal Price: $0.00 Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
