Speaker Request

Speaker Request Form

Shelley DeGroff, Founder and CEO, is a highly sought after speaker for dental industry events. If you would like to request Shelley to speak at your upcoming event, please complete form the below:

- Name*
  First Last
- Job Title*
- Organization*
- Email*
- Phone*
- Event Date*
  MM slash DD slash YYYY
  
  Approximate
- Event Location*
- Anticipated number of attendees
- Duration of presentation*
- Preferred learning objective of presentation*
- Description of the event and attendees*
- Is there an opportunity for PPO Advisors to exhibit at this event?*
  - Yes
  - No
- Other relevant details
- CAPTCHA
Name
This field is for validation purposes and should be left unchanged.