1

The Academy of General Dentistry (AGD) offers Constituents the opportunity to request the participation of the current AGD President in local Constituent events. If the AGD President is unavailable, then the President-Elect, followed by the Vice President may serve as AGD’s selected representative.

Please complete this form at least 4-6 weeks in advance of the meeting date. Requests will be taken in the order they are received.

PLEASE NOTE: All questions must be answered. Incomplete requests will not be considered until the missing information is provided.

If you have any questions or concerns, please contact CST at 888.243.7392.

Question Title

* 1. I understand that the AGD will approve only one official AGD representative to participate in Constituent events.

Other invited AGD representatives may attend at their own expense or that of the Constituent.

If the AGD President is unable to participate, the President-Elect, followed by the Vice President shall be invited.

Question Title

* 2. Constituent Name:

Question Title

* 3. Name of Event:

Question Title

* 4. Event type(s), please choose all that apply.

Question Title

* 5. Event Location (full address)

Question Title

* 6. Event Start and End Date/Time

Date
Time
Date
Time

Question Title

* 7. Constituent Contact Person for AGD President

Question Title

* 8. Required Arrival and Departure Date/Time for AGD President

Date
Time
Date
Time

Question Title

* 9. Description(s), date(s) and time(s) of official duties for AGD President (activities such as opening remarks, leader installations, etc.):

Question Title

* 10. Please upload the event agenda as a PDF file, Word file, Excel file, etc.

Please note that requests without an agenda will be considered incomplete (preliminary or working agendas are sufficient).

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 11. Will the Constituent be covering any expenses for the AGD President to attend the event (such as event registration, hotel, meals, airfare, ground transportation)?

T