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Bentson Clark & Copple

Contact Information

First Name:

Last Name:

Address:

Address 2:

City:

State:

Zip:

Home Phone:

Email:

Are you a US Citizen:

Yes No

If not, what VISA do you hold:

What US state are you licensed
to practice orthorthodontics:

Education

Ortho School Currently
Enrolled:

Anticipated month & year
of graduation:

Years in practice:

Preferences

Primary choice for state
in which to practice:

Preferred cities or regions
within this state:

US Geographic Preference
Check any other states below in which you might consider practice opportunities.
(by state - check as many as are applicable):

AL	AK	AZ	AR	CA	CO	CT	DE	FL	GA
HI	ID	IL	IN	IA	KS	KY	LA	ME	MD
MA	MI	MN	MS	MO	MT	NE	NV	NH	NJ
NM	NY	NC	ND	OH	OK	OR	PA	RI	SC
SD	SD	TX	UT	VT	VA	WA	WV	WI	WY

Future Plans

My future practice plans include:

Starting a private practice within US	Practicing with a family member
Buying into a practice as an associate/partner	Military
Academics	Other:

I have already located a
practice opportunity:

Yes No

If YES, with whom:

If NO, would you like to be registered in Bentson Clark's Free "Matching Program":

Yes No

Interested in financing information:

Yes No

How did you find out
about us:

Register with

Bentson Clark & Copple

Contact Information

Education

Preferences

Future Plans

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800.621.4664