a black and white photo of a smiling orthodontist in an orthodontic office .

APPLY TO BECOME A MEMBER

Thank you for your interest in becoming a Schulman Group member. Please fill out the application below and forward the required documents. We will review your application and contact you shortly.

*ALL INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED OUTSIDE THE MEMBERSHIP COMMITTEE AND SCHULMAN GROUP BOARD OF DIRECTORS.

SG MEMBERSHIP APPLICATION

FULL NAME & PROFESSIONAL CREDENTIALS (DDS, DMD, ETC.)

PRACTICE NAME (LIST LEGAL NAME AND DBA NAME IF APPLICABLE)

CELL PHONE

OFFICE PHONE

MAIN/PRIMARY OFFICE ADDRESS (GEOGRAPHIC EXCLUSIVITY APPLIES)

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PRACTICE INFORMATION

PRACTICE WEB ADDRESS

PRACTICE TYPE

ANNUAL COMBINED PRODUCTION OF ALL LOCATIONS

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**All owners must be SG members and fill out an application individually.

DO YOU HAVE OWNERSHIP IN ANY OTHER ORTHODONTIC INDUSTRY COMPANIES OR BUSINESSES?

IF YES, PLEASE EXPLAIN OWNERSHIP

NUMBER OF LOCATIONS

IN ADDITION TO YOUR MAIN PRACTICE, LIST ADDITIONAL PRACTICE LOCATIONS

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TELL US ABOUT YOU

HOW DID YOU HEAR ABOUT THE SCHULMAN GROUP?

HOW DO YOU FEEL YOU WILL BENEFIT THE SCHULMAN GROUP?

DO YOU KNOW ANY CURRENT MEMBERS IN THE SCHULMAN GROUP?

PLEASE LIST ANY SCHULMAN MEMBERS YOU KNOW

DO YOU OWN ANY OTHER DENTAL PRACTICES SUCH AS A PEDIATRIC DENTAL, GENERAL PRACTICE, OR ORAL SURGERY OFFICE?

IF SO, PLEASE LIST AND EXPLAIN

DO YOU HAVE A SPECIAL AREA OF INTEREST OR EXPERTISE IN ORTHODONTICS THAT YOU WOULD BE WILLING TO SHARE WITH MEMBERS IN A MEETING PRESENTATION? (SLEEP APNEA, SMILE ESTHETICS, LIGHTFORCE, ETC.)

IF SO, PLEASE EXPLAIN IN GREATER DETAIL

IS THERE ANYTHING ELSE YOU WOULD LIKE SCHULMAN TO KNOW ABOUT YOU

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SUBMISSION REQUIREMENTS

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Please submit the following 5 documents:

* PRACTICE TAX RETURN FROM 2 YEARS AGO

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*PRACTICE TAX RETURN FROM LAST YEAR

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* PROFIT/LOSS STATEMENT FROM 2 YEARS AGO

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* PROFIT/LOSS STATEMENT FROM LAST YEAR

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* PROFIT/LOSS STATEMENT FROM THE CURRENT YTD

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*These files are uploaded using secure encryption, however if you prefer to send them through email or another method, they can be submitted to: Ann Sebaugh, Director of Administration | annsebaugh@gmail.com | 314-623-3094

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MEMBERSHIP REQUIREMENTS

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CLICK HERE TO DOWNLOAD OUR MEMBERSHIP AGREEMENT

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PLEASE REVIEW THE MEMBERSHIP AGREEMENT ABOVE, AND CHECK THE BOX ACKNOWLEDGING THAT YOU UNDERSTAND THE TERMS OF MEMBERSHIP AND WILL AGREE TO THEM UPON ACCEPTANCE IN THE SCHULMAN GROUP.

mgmt@schulmangroup.com

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