The Academy of General Dentistry (AGD) offers constituents the opportunity to request the presence of an AGD official representative, which is the current AGD President. If the President is unavailable, then the President-Elect, followed by the Vice President may serve as AGD’s selected representative.

Please complete this form at least 4-6 weeks in advance of the meeting date. Requests will be taken in the order they are received and submitting one as soon as the event date(s) is confirmed is recommended.

PLEASE NOTE: Incomplete requests will be placed on hold until the missing information is provided.

If you have any questions or concerns, please contact us at 888.243.7392.

Please complete the following information:    Required = required field
1. Constituent Name Required
2. Constituent Contact(s) Required
  • Pre-Event Contact
    • Name:
    • Role/Title:
    • Email:
    • Telephone/Cell Phone:
  • Post-Event Contact (if different from the pre-event contact)
    • Name:
    • Role/Title:
    • Email:
    • Telephone/Cell Phone:
3. If the AGD President is unable to participate, please confirm that the President-Elect, followed by the Vice President shall be invited. Required
4. Event Type (choose all that apply). Choose all that apply. Submit a full meeting Agenda. Required

  
  
  
  
  
  
  
  
5. Event start and end date Required
All dates must be submitted in this format: MM/DD/YYYY
  • Required Arrival Date (to be there in time for their scheduled duties)
  • Date Event Starts
  • Date Event Ends
6. Location of Event (full address) Required
7. What is the airport closest to the event? Required
8. Please upload the event agenda as a PDF file, Word file, Excel file, etc. Please note that requests without an agenda will be considered incomplete (preliminary or working agendas are sufficient). Required
9. Description(s), date(s) and time(s) of official AGD Leader duties/activities (such as opening remarks, leader installations, etc.): Required
  Activity Title & Description Date Time Audience
1.
2.
3.
4.
5.
10. Constituent will reimburse invited AGD Leader with the following (select all that apply): Required
Airfare Number of Hotel Nights
Ground Transportation Parking
Per Diem Other
Constituent is unable to support invited AGD Leader expenses


If you do not receive confirmation of receipt, please contact the Constituent Services Team.