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

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* Speaker First Name

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* Speaker Last Name

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* What is your title? (DMD, DDS, RDH, etc.)

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* Are you a member of the ADA or other Dental Associations? If yes, please list

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* Phone Number

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* Email Address

Course Information

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* 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

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* Course Title

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* # of Hours/Credits

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* Please indicate your target audience

Disclosure of Relevant Financial Relationships and Conflict of Interest
Conflicts of Interest

ADA 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.

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* Disclosure - check one below and complete as appropriate

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

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* Grants/Research Support

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* Consultant

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* Stock/Shareholder

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* Governance

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* Requested Honorarium

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* Employee

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* Other financial or material relationship

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* 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:

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* (Please select the category that best represents your course submission)

Honorarium
*Please Note: It is NJDA's Policy not to pay honorariums to its members*

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* Do you require an honorarium?

*Only submissions with requested amounts can be included in the speaker directory. If no fee is required, please indicate with: n/a.

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* If yes, please share your requested fee.

Sponsors
Please list any companies that may sponsor your course (including your own organization):

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* Organization 1

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* Contact Name 1

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* Email Address 1

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* Phone Number 1

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* Organization 2

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* Contact Name 2

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* Email Address 2

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* Phone Number 2

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* Headshot
Please upload the required headshot in png or jpeg format.

PNG, JPG, JPEG file types only.
Choose File

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* 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.

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* 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.

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.

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