* 1. To register your predental club or chapter for ASDA's Predental Week and receive a promotional kit, please complete all fields below. Allow 5-7 business days for materials to arrive.

* 2. University Name:

* 3. ASDA Chapter or Predental Club:

4. Chapter or Predental Club Website:

* 5. Anticipated date of predental event:

Date
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* 6. Brief description of event:

* 7. Number of materials requested (due to limited quantities, we may not be able to send the quantity you request):

T