Northstar Orthodontics, INC. Graduate Rewards Program

Graduate Rewards Program Enrollment Form

NorthStar is pleased to reward those who work hard to achieve a brighter future! To help jump-start your career, we offer an exclusive 6-month incentive program for recent dental school graduates. Once approved, you are eligible to receive a 15% discount on all appliances ordered.*

Eligibility Details

To qualify for NorthStar’s Graduate Rewards Program you must meet the following criteria:

- Provide proof of graduation from an accredited college or university (Please provide proof of DDS, DMD or
dental specialty certification). This proof must be submitted to NorthStar within two years of your graduation date.

- Account must remain in good standing. If your account becomes delinquent (60 days past due) at any point
during your incentive program, you will become ineligible and will no longer receive benefits.

*Offer valid one (1) time per person. Discount offer is valid on cases submitted by the rewards program participant from the first month's statement through the sixth month's statement. Accounts enrolled in NorthStar’s Graduate Rewards Program are ineligible for any other volume discounts.

Please fill out the following form completely.
NorthStar will contact you once your application is processed and approved.

Have you applied for NorthStar's Graduate Reward program before? *

Yes No

Full Name *

Date of Birth *

Date

Name of Dental School *

Graduation Date *

Degree or Specialty Certification *

Dental License # *

State Licensed *

Current Practice Information

Clinic Name *

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

I certify that the information on this application is true and accurate. I grant NorthStar Orthodontics, Inc. permission to verify my eligibility with necessary parties. I understand that if I receive any rewards based upon false statements I may be subject to such penalties as afforded by the law. I have read and understand the rules and restrictions listed in NorthStar’s Graduate Reward Program eligibility details and disclaimers.

Signature *

Clear

Date *

Date