Please submit this form and provide a REQUIRED jpg or png of your headshot.
A separate form is required for each course.
For questions contact Rebekah Rosa or call 732-422-2722.
Speaker Contact Information
Disclosure of Relevant Financial Relationships and Conflict of Interest
Conflicts of Interest
ADA CERP considers that a conflict of interest may exist when an individual has an opportunity to affect the content of continuing dental education activities regarding products or services of a commercial interest with which he/she has a financial relationship.
Having an interest in or an affiliation with a corporate organization does not necessarily prevent you from making a presentation, but the relationship must be made known to the audience. Failure to disclose or a false disclosure will require (Provider Name) to remove you from the program and to identify a replacement for your participation.
Please list any companies (if any) that you have a financial relationship with in the following categories
ADA CERP is a service of the ADA that assists dental professionals in identifying quality providers of CDE. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. The NJDA's current term of recognition extends from November 2017 through December 2020. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP.
The New Jersey Dental Association requires that all course submissions clearly define the course content, objectives and identify the presentation category. NJDA defines the categories using the following category definitions.
NJDA Definitions of presentation categories:
*Please Note: It is NJDA's Policy not to pay honorariums to its members*
Please list any companies that may sponsor your course (including your own organization):
Please upload the required headshot in png or jpeg format.
If you receive an error message after hitting submit, please check the character count on your course description and speaker bio.