Step 1: Application

TRI-OLOGY Ambassador Program

Application Form
We will NEVER sell your personal information
First Name*
Last Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about TRI-OLOGY®'s Ambassador Program?

ReferralFacebookInstagramLinkedinMidwest Dental ConferenceOther
W-9 Information

For questions, refer to the IRS form W-9
Name as shown on your tax return*
Are you an:*

IndividualBusiness
Business Name (If Applicable)
Type of Business*

Individual/Sole Proprietor or Single Member LLCC-CorporationS-CorporationPartnership
Mailing Address - This will be used for tax purposes and mailing checks*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number or Employer Identification Number*
PROFESSIONAL INFO
License Number (If you are a student, please provide your expected graduation date)*
Years of Professional Experience
Professional Credentials*

RDHDDSDMDBDSDrMedDentStudent: RDHStudent: DDSStudent: BDSStudent: DrMedDentOther
Affiliations (Professional Organizations, Groups, etc...)
How many individual dental patients do you see monthly?
Education
Highest level of education achieved
If student, select which you are currently working on
Dental Practice Details
Practice Name*
May we contact this Dental Practice?

YesNo
Practice: Phone Number
Practice: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Name (if applicable)
Number of Dentists in practice?
Where does this practice purchase dental supplies?

Goetze DentalBurkhart DentalHenry ScheinPatterson DentalBanco DentalEssential DentalOther
Photo Release
I hereby grant the releasee permission to use photographs in web-based publications, print advertisements, and organization bulletin. I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.I understand and agree that photographs in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs.I hereby waive my right to inspect of approve the photographs by which my likeness appears.I hereby hold harmless, release, and forever discharge the from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.*

I agree to the Photo ReleaseI do NOT agree to the Photo Release
ADDITIONAL INFORMATION & AGREEMENTS
You will be issued a 1099 from NOWsystem, Inc if your annual income from the TRI-OLOGY Ambassador Program exceeds the federal minimum requiring a 1099 be issued*

I agree to be issued a 1099 (if required)
A Representative from TRI-OLOGY will contact you by phone if there are any questions or issues regarding your application.*

I agree to be contacted by a TRI-OLOGY Representative
AGREEMENTS
CLICK HERE to view Promotional Terms & Conditions of the TRI-OLOGY® Ambassador Program*

CLICK HERE to view Policies & Procedures of the TRI-OLOGY® Ambassador Program*

CLICK HERE to view the TRI-OLOGY® Ambassador Program Terms of Use*
Agreements*

I state that I have read, understood, and agree to the following documents: TRI-OLOGY® Ambassador Program Promotional Terms and Conditions, TRI-OLOGY® Ambassador Program Policies and Procedures, and TRI-OLOGY® Ambassador Program Terms of Use.
Please Enter your FULL Legal Name to Submit Agreement*
Please Enter the Date you are Submitting this Agreement*

MonthDayYear
Date
Should be Empty:

TRI-OLOGY Ambassador Program

W-9 Information

PROFESSIONAL INFO

Education

Dental Practice Details

Photo Release

ADDITIONAL INFORMATION & AGREEMENTS

AGREEMENTS