Star of the North Exhibitor Payment

Thank you for registering as an exhibitor at the Minnesota Dental Association’s Star of the North. Please complete the form below including entering the amount of payment you would like to make at this time.

If you have any questions, please contact Vicki Capistrant at 612-767-8400 or vcapistrant@mndental.org.

Star of the North Exhibitors

Name of person submitting payment:*
First Last
Name of Company Listed on Exhibitor Contract*
Phone*
Email for receipt*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Payment Amount*
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name