FOA Application: Non-Member FOA Application: Non-Member FOA Application: Non-Member Name* First Last FOA MembershipPreferred Email Address*(Your Future Login if Accepted)* Cell Phone Number*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Clinic Name*Simply part of the vetting process (even if not an owner, we want to learn about where you work) Dental License NumberEnter your dental license if you are the applicant. Please DO NOT enter a dental license number if you are not a Dentist. Job Title* Are you a member of AGD?*YesNoAGD NumberPlease enter your AGD number. Do you own multiple practices?*YesNoIf yes, please list them here.* Are you the main point of contact for your practice(s)?*If "No," please provide the main point of contact's information below. YesNoFirst and Last Name* Email* Position Title* How did you hear about us?*FriendInstagramFacebookPodcastOtherWhat is their name?*We would love to give them a free month for "Sharing the Love"! If other, tell us how!* Consent*CANCELLATION POLICY: Members can cancel at ANYTIME. All cancellation requests must be submitted through the “Contact Us” form located anywhere on the site. All cancellation requests submitted 24 hours prior to invoice due date will be charged. However, Front Office Academy will refund the total invoice amount. Any cancellation request submitted over the weekend will be reviewed and processed the next business day. For questions regarding FOA’s cancellation policy please contact tech@frontofficeacademy.com REFUND POLICY: All refunds are processed at FOA discretion excluding members who request to cancel membership within 24 hours of invoice due date. Members who have requested to cancel their membership within 24 hours of the invoice due date can expect a full refund. Refunds will not be processed to non-usage of the network. For questions regarding FOAs cancellation policy please contact tech@frontofficeacademy.com I agree to the Cancellation/Refund PolicyFinally, you understand that there is a fee of $179 due at the time of scheduling.*YesCredit CardCard Details Cardholder Name
