FOA Application: Non-Member

Name*
First Last
FOA Membership
Preferred Email Address*
(Your Future Login if Accepted)*
Cell Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Clinic Name*
Simply part of the vetting process (even if not an owner, we want to learn about where you work)
Dental License Number
Enter 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?*
AGD Number
Please enter your AGD number.
Do you own multiple practices?*
If 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.
First and Last Name*
Email*
Position Title*
How did you hear about us?*
What is their name?*
We would love to give them a free month for "Sharing the Love"!
If other, tell us how!*
Finally, you understand that there is a fee of $179 due at the time of scheduling.*
Credit Card
Card Details
Cardholder Name