PACE Provider Contact Form

Enter preferred salutation (Mr., Mrs, Ms., Dr., etc.)

*Contact person first name

*Contact person last name

Contact person suffix (Jr., Sr., III, etc.)

Contact person credentials (DDS, DMD, RDH, etc.)

Contact person title (Manager, Director, etc.)

*Contact person email

Contact person AGD member ID# (Leave blank if contact person is not an AGD member)

*Official organization name of continuing dental education (CDE) program provider

*CDE program provider street address

CDE program provider street address2

*CDE program provider city

*CDE program provider state/province (If none enter N/A)

For example, IL, NV, N/A

*CDE program provider zip (If none enter N/A)

*CDE program provider country

*CDE program provider phone

CDE program provider website

CDE program provider email, if different from contact person email

Preferred password to log in. If a preferred password is not provided the AGD will assign one.

Other organization type if not listed above:

Please check your business type:

For-Profit

Not-for-Profit

Nonprofit

Governmental Organization

Course types you plan to offer (check all that apply):

Lecture

Participation/Hands-on

Self-Instruction

Electronically-Mediated (including Webinars)

Live-Patient Training (patients are treated by instructor or participants during the course)

Protocol (homework assigned and results presented at a later date)

MasterTrack (Program designed to meet AGD Mastership Award Requirements)

FellowTrack (Program designed to meet AGD Fellowship Award Requirements)