2017 ACP Spokespersons Network Application Question Title * 1. Gender Male Female Question Title * 2. What is your first name? Question Title * 3. What is your last name? Question Title * 4. What is your email? Question Title * 5. What is your phone number? Question Title * 6. What city, state do you currently practice in? City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Question Title * 7. What is your practice URL: Question Title * 8. How long have you been an ACP member? Question Title * 9. Are you currently a donor to the American College of Prosthodontists Education Foundation (ACPEF)? (Only donors to the ACPEF are eligible to join the ACP Spokespersons Network.) Yes No Will make a donation today Question Title * 10. How many years have you been in private practice? Question Title * 11. What is your favorite procedure to perform as a prosthodontist? Question Title * 12. Please tell us about a recent patient case you found interesting and why: Question Title * 13. Media experience is not required of applicants, however please check off prior media experience(s) you may have: 0 times 1-3 times 4+ times TV TV 0 times TV 1-3 times TV 4+ times Radio Radio 0 times Radio 1-3 times Radio 4+ times Print Print 0 times Print 1-3 times Print 4+ times Online Online 0 times Online 1-3 times Online 4+ times Blog Blog 0 times Blog 1-3 times Blog 4+ times Journal article Journal article 0 times Journal article 1-3 times Journal article 4+ times Evidence- based research Evidence- based research 0 times Evidence- based research 1-3 times Evidence- based research 4+ times Leveraging social media channels Leveraging social media channels 0 times Leveraging social media channels 1-3 times Leveraging social media channels 4+ times Please elaborate (for example: which media outlet did you work with NBC, local paper, etc.) Question Title * 14. Why are you interested in applying to the ACP Spokespersons Network? Question Title * 15. If available, please copy and paste your CV below: Question Title * 16. Would you be interested in applying for a full scholarship (valued at $750) to cover the cost of Spokespersons Network Training? Yes No Thank you! Next