Speaker/Course Submission Form Please submit this form and provide a REQUIRED jpg or png of your headshot. A separate form is required for each course.For questions contact Brianna Oddo or call 732-422-2722. Speaker Contact Information Question Title * Speaker First Name Question Title * Speaker Last Name Question Title * What is your title? (DMD, DDS, RDH, etc.) Question Title * Are you a member of the ADA or other Dental Associations? If yes, please list Question Title * Phone Number Question Title * Email Address Course Information Question Title * Please upload a DOC or PDF containing your speaker bio(s) (limit to 500 characters), course description (limit to 750 characters), and course learning objectives (up to 6 objectives). PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please upload a DOC or PDF containing your speaker bio(s) (limit to 500 characters), course description (limit to 750 characters), and course learning objectives (up to 6 objectives). Question Title * Course Title Question Title * # of Hours/Credits Question Title * Please indicate your target audience Dentists New Dentists Hygienists Dental Assistants Office Staff Dental Residents Dental Students Disclosure of Relevant Financial Relationships and Conflict of Interest Conflicts of InterestADA CERP considers that a conflict of interest may exist when an individual has an opportunity to affect the content of continuing dental education activities regarding products or services of a commercial interest with which he/she has a financial relationship. Question Title * Disclosure - check one below and complete as appropriate I the undersigned declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program I the undersigned or an immediate family member have a financial interest-arrangement or affiliation with the corporate organization offering financial support or grant monies for this continuing dental education program Having an interest in or an affiliation with a corporate organization does not necessarily prevent you from making a presentation, but the relationship must be made known to the audience. Failure to disclose or a false disclosure will require (Provider Name) to remove you from the program and to identify a replacement for your participation. Financial Relationships Please list any companies (if any) that you have a financial relationship with in the following categories Question Title * Grants/Research Support Question Title * Consultant Question Title * Stock/Shareholder Question Title * Governance Question Title * Requested Honorarium Question Title * Employee Question Title * Other financial or material relationship Question Title * Describe Nature of Relationship ADA CERP is a service of the ADA that assists dental professionals in identifying quality providers of CDE. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. The NJDA's current term of recognition extends from November 2017 through December 2020. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP. Course Content The New Jersey Dental Association requires that all course submissions clearly define the course content, objectives and identify the presentation category. NJDA defines the categories using the following category definitions. NJDA Definitions of presentation categories: Question Title * (Please select the category that best represents your course submission) Basic Medical Science: presentations that have as their bases science of dealing with the maintenance of health and the prevention and treatment of disease. Clinical Observation: presentations that have as their basic clinical cases and obersvations and/or new concepts Evidence-based: presentations that have as their basis evidence-based data on research that has been peer-reviewed and publised in refereed journals Practice Management/Legal/Finance/Marketing: presentation that has as their basis practice management, legal, finance and/or marketing strategies Expert Panel: group panels, each presenter may select from the above categories Honorarium *Please Note: It is NJDA's Policy not to pay honorariums to its members* Question Title * Do you require an honorarium? Yes No *Only submissions with requested amounts can be included in the speaker directory. If no fee is required, please indicate with: n/a. Question Title * If yes, please share your requested fee. Sponsors Please list any companies that may sponsor your course (including your own organization): Question Title * Organization 1 Question Title * Contact Name 1 Question Title * Email Address 1 Question Title * Phone Number 1 Question Title * Organization 2 Question Title * Contact Name 2 Question Title * Email Address 2 Question Title * Phone Number 2 Question Title * HeadshotPlease upload the required headshot in png or jpeg format. PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File HeadshotPlease upload the required headshot in png or jpeg format. Question Title * Confirmation -Speaker shall be totally responsible for the content of the speaker's program, and hereby agrees to indemnify and hold harmless the NJDA from any liability to account thereof. By checking this box and submitting this form, you are attesting to the authenticity of any images presented to course participants and assure that non have been falsified in any way to misrepresent the outcome of treatment. I confirm that all images provided are genuine and have not been altered to misrepresent treatment outcomes. Question Title * Consent -We would like to support your interest in providing lectures. Check this box to give NJDA approval to share your program information with other organizations seeking speakers/presentations. I agree to allow NJDA to share my program information with other organizations seeking speakers or presentations. If you receive an error message after hitting submit, please check the character counts and ensure all required boxes have been checked and all required questions have been answered. Submit