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Please fill out the below application. This does not guarantee registration. Once reviewed you will get a follow-up email. If approved, that email will include an invoice to pay.

NOTE: Mari's List courtesy is excluded from early bird and express shipping registrations.

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Practice Name *

Students Full Name *

Practice Address *

Practice Email *

What is the full address you want course workbooks sent to?
*

Are you a Mari's list Member? *

Yes

What is your position within a practice? *

How many years of experience do you have within this position? *

Practice Phone Number *

Practice Website *

How many locations does your practice have? *

Age of Practice *

Number of Doctor/s *

Number of staff *

Number of staff wanting to attend the course *

Number of Practice Locations *

Practice Management Software *

Is your practice part of DSO? *

Yes

If your practice is part of DSO, which one? *

Is your Practice part of OSO? *

Yes

If your office is part of OSO, which one? *

Tell us your office network status *

Heavily in-network (10+ insurance companies)

In-network with only the big carriers (under 10 insurance companies)

In-network with only Delta

Completely out of network.

How did you hear about our course? *

Office Manager FB Group

Orthoprenuers FB Group

Mother of Pearl FB Group

Mari's List

其他：

If accepted, what are your goals for attending the course? *

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