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1. Please check the one category that best describes your primary occupation:

SELECT ONE ONLY Private Practice Part-time Faculty Full-time Faculty Hospital Staff Senior Year Dental Student Intern/Resident Graduate Student Business/Industry State or Local Govt. Dental Supply Dealer Dental Laboratory Other (please describe)
- - - - Federal Government - - - - Military Public Health Vets. Admins.

(if you selected other please specify): 

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2. What is your primary field of practice or specialty?

SELECT ONE ONLY General Practice Oral Surgeon Endodontist Orthodontist Pediatric Dentistry Periodontist Prosthodontist Oral Pathology Public Health Other (please specify):

(if you selected other please specify): 

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3. About how many hours per week do you provide direct patient care?

SELECT ONE ONLY 50 or more 40 - 49 30 - 39 20 - 29 Less than 20 None

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4. How many dentists work in your primary private practice?

SELECT ONE ONLY Four or more Three Two One

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5. Year of graduation from Dental School?

(Example: If you graduated in 99, enter in 1999. If you graduated in 00, enter in 2000.)

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6. How many oral hygienists do you employ?

SELECT ONE ONLY Three or more Two One None

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7. Gender (optional):

Male

Female

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8. This address is my:

Office

Home

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9. Would you be interested in participating in FREE educational web casts?

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10. I want to start/renew my free subscription to the following Dental Newsletters:

Dental Economics - Expert Tips & Tricks (bi-monthly).	Yes   No
Dental Assisting Digest (monthly).	Yes   No
Continuing Education Update (monthly).	Yes   No
RDH eVillage (monthly).	Yes   No
Proofs newsletter (monthly).	Yes   No

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11. Please send me information on Dental Shows:

PDA – Professional Dental Assisting

RDH - Under One Roof

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In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below the name of the last school you attended.

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