Application Form

Ambassador Program

Apply to be a Dimensions of Dental Hygiene Ambassador by submitting the form below

First name *

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Last name *

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Email *

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Address *

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Phone Number

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

License Number (if applicable)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Areas of Expertise (eg. public health, oral cancer, oral infections, advocacy, education, administration, dental research)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Website/Blog (if applicable)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Instagram (if applicable)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Please enter a valid Instagram URL starting with https://www.instagram.com/

Instagram Following

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Facebook (if applicable)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Please enter a valid Facebook URL starting with https://www.facebook.com/

Facebook Following

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Twitter (if applicable)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Please enter a valid Twitter URL starting with https://twitter.com/

Twitter Following

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Why would you make a good Dimensions of Dental Hygiene Ambassador? *

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Industry Affiliations or Employment

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Online Activities (outside of social media)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Were you referred by someone? (If yes, please enter their first and last name)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

Are you a dental hygiene student? (yes/no)

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

If yes, what is your expected graduation date?

This field is required

Please enter a valid email address

Please enter a valid web address. Must start with http:// or https://

By agreeing to serve as a Dimensions of Dental Hygiene Brand Ambassador, I agree that my profile and bio sketch may be used in promotional materials from time to time. *

Please tick to accept

By applying, you agree to our terms of service and privacy policy.

Thanks! One last thing...

Please verify your email by clicking on the link we just sent.

Don't see it? Be sure to check any spam folders.

To ensure you receive our follow up emails, please add info@dimensionsofdentalhygiene.com to your contacts
(and to your safe senders list, if using Outlook).

We'll be in touch soon!