AO Master and Diplomate Certificates Authorized Training Center application -

Academy of Osseointegration Authorized Training Center Application

Thank you for your interest in becoming an AO Authorized Training Center. Please complete and submit the form below. After your application has been reviewed by committee, you will be contacted. If you have any questions about this application, please contact Kevin Smith, AO Executive Director, at kevinsmith@osseo.org.

Please enable JavaScript in your browser to complete this form.

- Step 1 of 8

Applicant's full legal name and any acronyn or other names used *

Please indicate proposed institution with primary responsibility for implementing the Master/Diplomate training course.

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email: *

Applicant's Primary Phone: *

U.S. and international numbers accepted

Applicant's cell phone:

Website URL:

Jurisdiction in which Institution is incorporated or legally formed (country): *

Save and Resume Later

PROPOSED QUALIFIED INSTITUTION - Full legal name and any acronym or other names used by proposed Qualified Institution: *

Please indicate proposed institution with primary responsibility for implementing the Master/Diplomate training course

Institution's Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Institution's primary phone number: *

Institution's website address (include full http:// URL):

Jurisdiction in which Institution is incorporated or legally formed: *

Identify the program or organization by which the Institution (and any additional institutions affiliated with this training course) is currently accredited:

(e.g., ADA CERP, AGD PACE)

Will any Courses be held at university centers, medical schools, hospitals, or private practices other than the Institution stated above?

List the full legal name(s) and addresses of each university center, medical school, hospital, or private practice. NOTE: At least one (1) module of the Course must be in a U.S. based university. (Upload documents separate documents below):

You may either list the information in this field or submit as a separate attachment.

Save and Resume Later

DIRECTOR INFORMATION - Is proposed Director the same as Applicant? *

Director's name:

Director's phone number:

Director's Email address:

Director's dental degree (check all that apply):

DDS
DMD
MSD
Other (Please describe in field below)

If you selected 'Other' please describe:

State (or equivalent) and country in which Director is currently licensed to practice dentistry:

In what type of practice does Director work (check all that apply)?

Private
Academic
Other (please describe in field below)

If you selected "Other" please describe:

U.S. or Regional teaching university at which Director holds an appointment (if applicable):

Check here to confirm Director holds an active license to practice dentistry:

I confirm Director's active license

Check here to confirm Director has teaching privileges at the Institution:

I confirm Director's teaching privileges

Check here to confirm Director is an AO member:

I confirm Director's AO membership

Check here to confirm Director is not a member of the AO Board of Directors, nor a family member or business colleague of any member of the AO Board of Directors:

I confirm eligibility

Director's curriculum vitae in implant dentistry is required. Please choose how you will submit the information:

Submit as separate attachment
Enter information in field below

If not included in Director's C.V, describe the Director's experience in implant dentistry, including documented surgical and/or restorative clinical, and instructive and administrative experience (upload files below):

You may enter description in this field or attach as separate document

DOCUMENT UPLOAD: Upload documents that describe the Director's experience in implant dentistry, including documented surgical and/or restorative clinical, and instructive and administrative experience (upload files below):

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here (only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff).

Save and Resume Later

FACULTY MEMBERS (limited to 4) - Detailed information is required for each proposed faculty member. Please indicate how this information will be submitted.

Information is submitted in attached document file
Information is included in fields below

Faculty #1 - Name

First

Last

Faculty #1 - Email

Faculty #1 - Primary Phone

Faculty #1 dental degree (check all that apply)

DDS
DMD
MSD
Other (Please describe in field below)

If you selected 'Other' please describe:

State and Country in which Faculty #1 is licensed to practice dentistry:

Faculty #1 type of practice (check all that apply)

Private
Academic
Other (Please describe in field below)

If you selected 'Other' please describe:

ADDITIONAL DOCUMENT UPLOAD - upload documents with the following information about Faculty #1 if not already reflected in the C.V.: 1) U.S. regional teaching university at which Faculty holds an appointment; 2) describe experience in the topic area including lecture experience; 3) list presentations at scientific meetings and/or continuing education courses.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff).

U.S. or regional teaching university at which Faculty #1 holds an appointment (if applicable):

If not reflected in the C.V., describe Faculty #1's experience in the assigned topic area, including lecturing experience:

If not reflected in the C.V, describe Faculty #1's scholarly activities (e.g. basic research, publications in peer-reviewed scientific publications:

If not reflected in the C.V, list Faculty #1's presentations at scientific meetings and/or continuing education courses:

Are there additional faculty members:

FACULTY #2 - Detailed Information is required. Please indicate how this information will be submitted:

Information in attached document file
Information included in fields below

Faculty #2 - Name

First

Last

Faculty #2 - Email

Faculty #2 - Phone

Faculty #2 dental degree (check all that apply)

DDS
DMD
MSD
Other (Please describe in field below)

If you selected 'Other' please describe:

State and country in which Faculty #2 is licenses to practice dentistry:

Faculty #2 type of practice (check all that apply):

Private
Academic
Other (please describe below)

If you selected 'Other' please describe:

ADDITIONAL DOCUMENT UPLOAD: Upload documents with the following information about Faculty #2 if not already reflected in the C.V.: 1) U.S. regional teaching university at which Faculty holds an appointment; 2) describe experience in the topic area including lecture experience; 3) list presentations at scientific meetings and/or continuing education courses.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff)

U.S. or regional teaching university at which Faculty #2 holds an appointment (if applicable):

If not reflected in the C.V., describe Faculty #2's experience in the assigned topic area, including lecturing experience:

If not reflected in the C.V., list Faculty #2's presentations at scientific meetings and/or continuing education courses:

Are there additional faculty members?

FACULTY #3 - Detailed Information is required for faculty member #3. Please indicate how this information will be submitted:

Information in attached document file
Information included in fields below

Faculty #3 - Name:

First

Last

Faculty #3 - Email:

Faculty #3 - Phone:

Faculty #3 dental degree (check all that apply):

DDS
DMD
MSD
Other (please describe below)

If you selected "Other" please describe:

State and country in which Faculty #3 is licensed to practice dentistry:

Faculty #3 type of practice (check all that apply):

Private
Academic
Other (please describe below)

If you selected "Other" please describe:

ADDITIONAL DOCUMENT UPLOAD: Upload documents with the following information about Faculty #3 if not already reflected in the C.V.: 1) U.S. regional teaching university at which Faculty holds an appointment; 2) describe experience in the topic area including lecture experience; 3) list presentations at scientific meetings and/or continuing education courses.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff)

U.S. or regional teaching university at which Faculty #3 holds an appointment (if applicable):

If not reflected in the C.V., describe Faculty #3's experience in the assigned topic area including lecturing experience:

If not reflected in the C.V., list Faculty #3's presentations at scientific meetings and/or continuing education courses:

Are there additional faculty members?

Faculty #4 - Detailed information is required. Please indicate how this information will be submitted:

Information in attached document file
Information included in fields below

Faculty #4 - Name:

First

Last

Faculty #4 - Email:

Faculty #4 - Phone:

Faculty #4 dental degree (check all that apply):

DDS
DMD
MSD
Other (please describe below)

If you selected "Other" please describe:

State and country in which Faculty #4 is licensed to practice dentistry:

Faculty #4 type of practice (check all that apply):

Private
Academic
Other (please describe below)

If you selected "Other" please describe:

ADDITIONAL DOCUMENT UPLOAD: Upload documents with the following information about Faculty #4 if not already reflected in the C.V.: 1) U.S. regional teaching university at which Faculty holds an appointment; 2) describe experience in the topic area including lecture experience; 3) list presentations at scientific meetings and/or continuing education courses.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff)

U.S. or regional teaching university at which Faculty #4 holds an appointment (if applicable):

If not reflected in the C.V., describe Faculty #4's experience in the assigned topic area, including lecturing experience:

If not reflected in the C.V., describe Faculty #4's presentations at scientific meetings and/or continuing education courses:

Save and Resume Later

FACILITIES & RESOURCES: Description of facilities and resources is required. Please select the method to submit information:

Submit as separate attachment
Enter information in field below

Describe the facilities, education resources, education experiences and opportunities to which you (as Applicant) will ensure the Participants have access (e.g., administrative offices, instructional space, personnel resources, health science library, current electronic medical literature databases with search ccapabilities, reference materials in print or electronic format, etc.)

DOCUMENT UPLOAD: Attached document should describe the facilities, education resources, education experiences and opportunities to which you (as Applicant) will ensure the Participants have access (e.g., administrative offices, instructional space, personnel resources, health science library, current electronic medical literature databases with search capabilities, reference materials in print or electronic format, etc.)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff)

Save and Resume Later

Please upload all C.V. attachments for all listed Faculty members:

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Upload one or more documents here. (Only these file formats will be accepted: doc, docx, gif, jpeg, jpg, pdf, png, tiff)

Save and Resume Later

VERIFICATION OF ACCURACY: Please check the box below to verify accuracy of information: *

I hereby certify that all information submitted on this application and any attached documents are accurate and support my application.

SIGNATURE AGREEMENT: Please check the box below to verify agreement with requirements and terms: *

The undersigned, who will serve as Director if Applicant becomes an ATP, represents, warrants, and agrees: (i) the undersigned is duly authorized to execute and submit this Application on Applicant's behalf; (ii) the undersigned read and understands this Application, including the Conflict of Interest Form, and the Requirements; and (iii) if the Applicant becomes an ATP, Applicant is bound and shall abide by the Requirements and the terms of Conflict of Interest Form (collectively, "Agreement"), which will constitute the binding Agreement between Applicant and AO.

Electronic Signature:

Clear Signature

Please use your mouse or touch screen to enter your signature.

Signer's full name: *

Save and Resume Later

Thank you! Your application will be forwarded to the Review Board for approval. Once approved, you'll be contacted by AO to submit the $7,500.00 application fee. At that point, payment can be made by credit card, check, or wire transfer. *

I have read and understand terms of payment.

Save and Resume Later

PLEASE NOTE: Saving your progress now will store a copy of your entry on this server and the site owner may have access to it. For security reasons, sensitive information such as emails and/or phone numbers, along with file uploads will have to be re-entered when you resume.

Go Back

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Academy of Osseointegration Authorized Training Center Application

Academy of Osseointegration

CONTACT US

QUICK LINKS

WEBSITE POLICY