Schulman Group

APPLICATION

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.

FULL NAME & PROFESSIONAL CREDENTIALS (DDS, DMD, etc.)*

PRACTICE NAME (List legal name and DBA name if applicable)*

EMAIL*

CELL PHONE*

OFFICE PHONE*

MAIN/PRIMARY OFFICE ADDRESS (Geographic exclusivity applies)*

Street Address City State / Province / Region ZIP / Postal Code Country

PRACTICE INFORMATION

PRACTICE WEB ADDRESS*

PRACTICE TYPE*

Solo Orthodontic Practice
Single Orthodontic Practice with Associate(s)
Multi-owner Orthodontic Practice/Partnership
Multi-specialty Practice

ANNUAL COMBINED PRODUCTION OF ALL LOCATIONS*

2 million to 3 million
3 million to 4 million
4 million or greater

**ALL OWNERS MUST BE SG MEMBERS AND FILL OUT AN APPLICATION

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

Yes
No

IF YES, PLEASE EXPLAIN OWNERSHIP

NUMBER OF LOCATIONS*

One
Two
Three or more

IN ADDITION TO YOUR MAIN PRACTICE, LIST ADDITIONAL PRACTICE LOCATIONS

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?*

Yes
No

PLEASE LIST ANY SCHULMAN MEMBERS YOU KNOW

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

Yes
No

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.)*

Yes
No

IF SO, PLEASE EXPLAIN IN GREATER DETAIL

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

SUBMISSION REQUIREMENTS

Please submit the following documents:
* 2022 & 2023 practice tax returns
* 2022 & 2023 profit/loss statements.
* 2024 Year-to-date profit/loss statement

Submit to:

Ann Sebaugh, Director of Operations
314-623-3094
annsebaugh@gmail.com

MEMBERSHIP REQUIREMENTS

Membership Agreement-Click Here

Please review the membership agreement above. Please check the box acknowledging that you understand the terms of membership and will agree to them upon acceptance in the Schulman Group.

I accept and agree

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