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Fellowship Nomination Referral

ICD World Headquarters
Operations Center
Flint, Michigan, USA

Re: Fellowship Nomination

Please consider the following dentist for fellowship in our College (include as much of the requested information as known). The name will be referred by the College Office to the relevant Section for consideration.

    Name

    Email

    Telephone Number

    City / State / Country

    Check below if appropriate:
    Please contact me so I can discuss this nominee or comments about the nomination process.

    Please provide your contact details: (Only a Fellow of the College can sponsor a nomination).

    Name

    Country

    Telephone Number

    Email

    Your ICD Section