DSI Associate x DSN Membership Application DSI Associate x DSN Membership Application Name* First Last Preferred DSN Email Address*(Your Future Login if Accepted)* Cell Phone Number*Please provide the best cell number to receive the most up-to-date news and announcements. We will never spam you or share your info with anyone.Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country When would be a good time to contact you?*Clinic Name*Simply part of the vetting process (even if not an owner, we want to learn about where you work)How many clinics are you an owner in, if any?*If an Associate, enter 0. Dental License Number*AGD NumberAre you a member of the AGD? If so, please provide AGD number for online CE submission. Annual Revenue*Please SelectLess than $1,000,000$1,000,000 - $2,000,000$2,000,000 - $3,000,000$3,000,000 - $4,000,000$4,000,000 - $5,000,000$5,000,000 - $6,000,000$6,000,000 - $7,000,000$7,000,000 plusDSN Members and faculty openly share information because this is a place of empowerment. Privacy is respected and valued.*As part of this community, you will gain access to clinical and business secrets & battle-tested insights of industry leading experts. Do you agree to keep this information confidential?* Yes No DSN members check our egos at the door. We share our challenges openly and humbly so as to shortcut the feedback process and get the answers we need. Same team: dentists! Watch what WE can build.*Do you agree to contribute to the community by sharing your challenges and successes so we can all learn from each other? Yes No Our intentions are pure...We accept ZERO vendor kickbacks! All the savings go to you (avg. 10-55%). This is unprecedented and vendors are shocked to hear this.*If you are accepted, you enter a 45-Day vetting period, to ensure fit. After this vetting period you will have access to BIG discounts, to our trusted vendors, to our CE, and to a few other surprises. Can we trust you to not share your access to these benefits with non-members?* Yes No DSN provides our partners with a list of our members and contact information so you don’t miss a beat in savings with suppliers you may already be using!*We understand and value our member's privacy. If sharing your office information with our partners is something you would like to opt-out of, we get it! Simply click "Do not share my information". Yes, share my information with DSN vendors No, do not share my information with DSN vendors What part of the Dental Success Network are you most interested in?* Savings & Vendor Discounts Team Training Continued Education Startup & Acquisition Growing My Practice What three challenges can we help you solve?**Please Select Three Systemization Implementation Team Culture Become a Better Leader Understanding Cash Flow Inventory & Overhead Control Understanding My Business Shirt Size* Extra Small Small Medium Large Extra Large DSN MembershipConsent*CANCELLATION POLICY: Members can cancel at ANYTIME. All cancellation requests must be submitted through the “Contact Us” form located anywhere on the site. All cancellation requests submitted 24 hours prior to invoice due date will be charged. However, Dental Success Network will refund the total invoice amount. Any cancellation request submitted over the weekend will be reviewed and processed the next business day. For questions regarding DSN’s cancellation policy please contact support@dentalsuccessnetwork.com REFUND POLICY: All refunds are processed at DSN discretion excluding members who request to cancel membership within 24 hours of invoice due date. Members who have requested to cancel their membership within 24 hours of the invoice due date can expect a full refund. Refunds will not be processed to non-usage of the network. For questions regarding DSN’s cancellation policy please contact support@dentalsuccessnetwork.com I agree to the Cancellation/Refund Policy.Finally, you understand that, if accepted, there is a monthly membership fee of $79 per month once your 7 day free trial expires*This is a NO CONTRACT, CANCEL ANYTIME approach because we want you in Position #1...finally. Why pay? Communities that pay, pay attention. This ensure we have a high-quality group of Members and that we can pay our EXPERTS and the most influential people in dentistry paid to pay attention to YOU!* Yes It looks like you answered NO to one of our Core Value Questions and that Dental Success Network might not be the right fit for you. If you feel you have received this message in error please go back and re-submit your application.Credit Card*Card Details Cardholder Name
