Continuing Education Course Verification
Your Name:
Your Address:
Address, line 2:
Address, line 3:
ADA Membership Number:
AGD Membership Number:
Course Date(s):
Course Title:
Instructor Name:
CE Program Provider Name:
CE Program Provider's AGD Code:
AGD Subject Code: Number of Hours:
AGD Subject Code: Number of Hours:
Course Type (Participation or Lecture):
Verification Code:
Location — City & State:
Signature: _________________________________________
Date: _____________________________
All Participants:
- Complete all lines
- Print out this form -
- Keep a copy for your records
Academy of General Dentistry members:
- Fax to the AGD at 1-312-335-3432
- or Mail to: Academy of General Dentistry, Attn: CE Entry, 211 East Chicago Ave Ste 900, Chicago IL 60611