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:

  1. Complete all lines
  2. Print out this form -
  3. Keep a copy for your records

Academy of General Dentistry members: