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!*
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 Policy
Finally, you understand that there is a fee of $179 due at the time of scheduling.*
Credit Card
Card Details
Cardholder Name

FOA Application: Non-Member

FOA Application: Non-Member

FOA Application: Non-Member

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