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Smile Usa | Sri Lanka Mini Residency Form

Sri Lanka Mini Residency Form

Course Fee USA fee payment of USD $4,000.00 in favor of “Smile USA” by way of a demand Draft/Banker’s cheque.

Payable to “Smile USA”.
Account No 20000 3904 6509
Bank Details Wachovia Bank 141 Elmora Ave., Elizabeth, NJ 07202
Swift Code PNBPUS33
ABA# 031201467

***Note: Additional Fee of $960.00 for the local component and logistics made payable to “Postgraduate Dental Academy (Pvt) Ltd, Sri Lanka”

REGISTRATION FORM
Sri Lanka Mini Residency
Venue- Kandy / Colombo - Sri Lanka
2015 - 2016
Name
*This will appear on the certificate*
* Mandatory *
E-mail
* Mandatory *
* Invalid E-mail *
Date of Birth
* Mandatory *
Sex
MaleFemale
State of Registration/Practising
* Mandatory *
Office Phone Number
Residence Phone Number
Mobile Number
* Mandatory *
Fax Number
Address
City
State
Zip
Country
Your Photo