About You

Please fill form out completely and upload a recent headshot of the Nominee.

Date: MM/DD/YYYY *

Name as you would like it to appear on the Certificate *

Street Address *

Street Address Line 2

Add A Headshot of the Nominee *

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State / Province / Region *

Postal / ZIP Code *

City *

Country *

Email Address *

Home or Cellular Phone Number *

Office Phone Number *

Date of Birth: MM/DD/YYYY *

Please attach a copy of your CV *

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Dental Education

Please list Dental School, Specialty or Advanced Degree Programs

Dental School Attendance *

Year Graduated: MM/DD/YYYY *

Degree *

Post-Graduate/Specialty School Attendance

Year Graduated: MM/DD/YYYY

Post-Graduate/Specialty School Degree

Other Post Dental School Graduate Attendance

Year Graduated: MM/DD/YYYY

Other Post-Graduate/Specialty School Degree

Dental Organization Membership

Membership in the American Dental Association or Other Dental Organization is a requirement for Fellowship.

Name of Dental Organization

Major Accomplishments

Briefly list your top 5 accomplishments or activities that you feel coincide with the objectives of the Pierre Fauchard Academy

Major Accomplishments/Activities

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About You

Dental Education

Dental Organization Membership

Major Accomplishments

Region 1 - Europe

Region 2 - Northeast USA

Region 3 - Southeast USA

Region 4 - Midwest USA

Region 5 - Western USA

Region 6 - Canada

Region 7 - Latin America

Region 8 - Australasia

Region 9 - Asia

Region 10 - Central USA

Region 11 - Africa

Autonomous Region