WA Top Dentists Application Form

Contact Information

Practice Name*

Doctor's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Office Phone*

Office Fax*

Office Email

Doctor Email*

Contact Person*

First Last

Contact Email*

Best Contact Number*

Best Contact Method*

Phone
Email
Fax
Mail

Website

Number of Locations

Specialty/Specialties*

Education & Training

Dental School*

Year of commencement*

Residency Institution

Year of commencement

Do you meet your Continuing Education requirements*

Yes
No

Please list any additional education &/or certification information you would like to include:

Appointments & Awards

Do you currently have any hospital appointments*

Yes
No

Please provide details below

Do you currently have any teaching appointments*

Yes
No

Please provide details below

Do you currently hold any administrative posts*

Yes
No

Please provide details below

Please provide a brief list of the major organizations you are a member*

If you have any additional information you wish to share with the selection committee (publications, charitable works, research, technological advances in your practice, etc.) please detail below*

Affirmation

By signing this form I certify that all the information above is true to the best of my knowledge and held to be true. I also understand and agree that WA Top Docs may in their sole discretion, decline accept my application with or without cause. I understand and agree that WA Top Docs will conduct a background check (free of charge to myself) to review my license, malpractice, education, training and employment.

Signed*

Electronic Signature

By Checking This Box, I Am Signing This Application

Date*

Name*

First Last

Phone

This field is for validation purposes and should be left unchanged.