Speaker Application

Name*

First Last Credential Abbreviations (DDS, RDH, etc.)

Company and/or Sponsor

Cell Phone Number*

Email

Your Biography*

Course Name*

Course Description*

Length of Course*

Example: 1.5 hours, 3 hours, etc.

Learning Objectives:*

What is the course type:

What certifications will your course provide? (Select all that apply)*

Days Available to Present (Select All Your Availability)*

Select Your Target Audience*

File: Please upload your professional portrait photo (high resolution preferred)*

This is required as it will be used for all marketing materials. If your course is approved, you give us full permission to utilize this image.