Affiliate Manual Application (Goodman)

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.

Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
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 Number*
If you do not have an AGD Number, enter 0
Annual Revenue*