Dental Study Club

APPLICATION FOR MEMBERSHIP IN THESIMPLY IMPLANTS DENTAL STUDY CLUB, LLC
I am applying for membership in the Simply Implants Dental Study Club, LLC. I certify that:

1. l hold an active license to practice dentistry in the USA in the State(s) of State or in Canada in the Province of Province

2. I will follow, and agree to governed by, the "Articles of Association" for the Simply lmplants Dental Study Club, LLC.

3. I agree to pay in advance for all continuing education programs and hands-on demonstrations.

4. I understand that when I give hands-on demonstrations before the SIDSC, LLC, that my treatment will be free of charge to the person(s) on whom made, and I will receive no payment
or other compensation for doing so.

5. I have dental malpractice insurance as listed below and have informed my carrier that will be giving hands-on demonstrations for SIDSC in the State of Arizona.
Name:
Practice Address:
Email:
example@example.com
Office telephone:
Cell phone
Insurance:
Name of Dental Malpractice Carrier
Limits per claim, e.g. $1M
Have you informed your carrier in writing that you will be performing dental services for the SIDSC in the state of Arizona?

YesNo
Have you received written confirmation that your carrier will cover any alleged malpractice for services provided for the SIDSC in the state of Arizona?

YesNo
Proof of coverage in Arizona (an email) from your insurance company must be attached to this application.

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APPLICATION FOR MEMBERSHIP IN THESIMPLY IMPLANTS DENTAL STUDY CLUB, LLC