Office Management Academy Application To finish your application, please fill out the form below. Select Date* September 21 & 22, 2023 February 8 & 9, 2024 Location: 22660 SE Stark St, Gresham, OR 97030 Course Hours: Thursday (8:30am - 4:30pm)Friday (8:30am - 12:00pm) Included: 3 months of post-course support. Each course is two days with a catered lunch, and an afternoon reception on the first dayName First Last Date MM slash DD slash YYYY Practice Name Doctor's Name Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell PhoneOffice PhonePersonal Email Website Doctor's Email Average Monthly StartsAge of your PracticeNumber of StaffNumber of DoctorsNumber of Offices/SatellitesOffice Software How Many Years Have You Been at the Practice?Is Your Office Part of a Dental Service Organization? Yes No Member ID# Have You Attended Any of Our Courses or Lectures? Yes No Which Courses? Are You a Private Client of Peniche & Associates? Yes No Practice GoalsAre You a Mari's List Member? Yes No Are You an OrthoFi Member? Yes No Are you an Elite Dental Alliance Number? Yes No Elite Dental Alliance # Special Discount Code Whom may we thank for referring you to our workshop? Mailer Internet Other How Many Will Be Attending?If you're accepted, your confirmation packet will be sent to you via email and will include instructions to assist you in booking your hotel reservations. Please confirm registration prior to booking your travel arrangements. CAPTCHA