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Name_________________________________________________________________________ Address_____________________________________________City_______________________ State_______ Zip Code___________ Telephone__________________ Fax_________________ How many years experience do you have in the orthodontic profession?____________________ In what areas of the office do you have experience? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Who is your current employer?_____________________________________________________ How many orthodontists have you worked for?________________________________________ Do you have any experience with public speaking? If yes, please explain. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you ever taught in a small or large group setting? If yes, please explain. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you ever held the position as a manager or leader in the orthodontic field? If yes, please explain. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ How do you feel about traveling and time spent away from home? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you feel that your current situation would allow you to travel for work? _____________________________________________________________________________________________ _____________________________________________________________________________________________ What is your experience with handling and solving conflicts? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you consider yourself to be open-minded and fair when dealing with different types of individuals? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you consider yourself to be self-driven to accomplish tasks? What motivates you? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ How do you handle new situations and meeting new people? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ What do you love about the orthodontic profession? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ What skills and traits do you possess that would qualify you to become an orthodontic consultant? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Why do you want to become an orthodontic consultant? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Applicants will be notified on or before August 31,2007 if they have been accepted into the seminar. Along with the confirmation letter will be an invoice for the balance of the registration fee and further details. Applicants not accepted will be refunded the application fee no later than August 31, 2007. Please send completed registration form with a $500 application fee to: Debbie Best, Consulting Network 2137 Bella Vista Place Livermore, CA 94550
