Endo CE Event Proposal Form
This form should be completed, reviewed, and your event fully approved by your Area Director and Professional Affairs BEFORE you submit your event request via CVENT. Please complete each of the required fields below.
Important Reminder on Lead Times
For lecture-only courses, a 90-day lead time is required. For hands-on courses, a 120-day lead time is required. If your event request is within the aforementioned lead time, your event may not be approved.
Name
*
First Name
Last Name
Email
*
first.last@dentsplysirona.com
Date of Form Submission
*
-
Month
-
Day
Year
Select your Area
*
Please Select
Great Lakes
Mid Atlantic
Mid South
North Central
Northeast
Northwest
Southeast
Southwest
South Central
Great Lakes - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Stephen.Vredenburgh@dentsplysirona.com
Mid Atlantic - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Jennifer.Romanelli@dentsplysirona.com
North Central - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Roger.McKnight@dentsplysirona.com
Northeast - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Guy.Puglisi@dentsplysirona.com
Northwest - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Colby.Ledbetter@dentsplysirona.com
Southwest - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
Steve.Andregg@dentsplysirona.com
Midsouth - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
amy.kidd@wellspect.com
Southeast - Paste the email found in the dropdown in the subsequent section 'Area Director Email'
*
Please Select
travis.bedwell@dentsplysironacom
Area Director Email
*
Copy the email from the field above into the box. This email will trigger the approval to your Area Director, so please ensure you've copied the email exactly as found above.
Area Director Email
Copy the email from the field above into the box. This email will trigger the approval to your Area Director, so please ensure you've copied the email exactly as found above.
Event Date
*
-
Month
-
Day
Year
Estimated Budget
*
Objectives (select all that apply)
*
Product or procedural innovation
Basic Clinical Education
Intermediate Clinical Education
Advanced Clinical Education
Business Management
Cross-Department Procedural Education (e.g. RCT with 3D CBCT)
Other
Target Customer (select all that apply)
*
Low to Moderate Volume GP
High Volume GP
Endodontist
DSO
University
Other
Will this event be Live or Virtual?
*
Live
Virtual
Course type (Select all that apply. Please note: lecture-only courses require a 90-day lead time and hands-on courses require a 120-day lead time).
*
Lecture only
Hands-on
Lecture and hands-on
Please confirm this event allows for 90-day lead time required for lecture-only courses
*
Please Select
Yes, this event complies with the required lead time
No, this event does not comply with the required lead time
Please confirm this event allows for the 120-day lead time required for a hands-on course
*
Please Select
Yes, this event complies with the required lead time
No, this event does not comply with the required lead time
Please indicate the intended duration of the course (e.g. 2 hours, half-day, full day)
*
Course Content (Select all that apply):
*
Foundational Endo
Endo + Resto
Endo + Imaging
Endo Trouble Shooting
Mastery Level Endo
Which focus products will be featured? (select all that apply)
*
ProTaper Ultimate
WaveOne Gold
TruNatomy
AHPlus Bioceramic Sealer
EndoActivator
Other
If you have a preferred Speaker, please enter the name(s) of your preferred speaker(s) below. Please note, this speaker is not guaranteed to participate. Speakers are selected and approved based on a variety of factors, including availability, fees, and content specialty.
If you have a first, second, third choice, please indicate this in the box above.
Expected event attendance (select one)
*
1-10
11-20
21 and up
Please provide the expected leads, sales, or opportunities resulting from this event. For example, how many new customers will you convert? What are the potential sales throughout the next 3-6 months?
*
Check this box to confirm edits:
*
I've added all requested information
Submit
Should be Empty: