For Community Advocates

The password must have a minimum of 8 characters of numbers and letters, contain at least 1 capital letter

Organization/Workplace

Dental License Number (Enter 0000 if you do not have a number)

Zip Code of Residence

County of Residence

Zip Code of Workplace

County of Workplace

Please choose your primary position

If you hold a license/certification, please choose the option that includes that.

Please choose your secondary position (optional)

If you hold a license/certification, please choose the option that includes that.

August 2024