45 Day Free Trial Application 45 Day Free Trial Membership Application (Dr. Addison Killeen) Name* First Last Preferred DSN Email Address*(Your Future Login if Accepted)* Cell Phone Number*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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 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. Please enter a number from 0 to 99.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 What part of the dental success network are you most interested?* Select All Workplace Community Vendor Discounts Continuing Education Team Training DSN MembershipFinally, you understand that, if accepted, there is a monthly membership fee of $199 per month once your 45 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! Dental Whale Savings Network will NOT be included during your 45 day free trial * 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
