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)

Pace Provider Contact Form