Implanting Inspiration Application If you are interested in participating in the Implanting Inspiration program, please complete the application below. Not all applicants will be eligible to participate. Those candidates that are selected will receive ONE free dental implant and must be available to receive services in 2019. If you are selected to participate in the program, you will be contacted no later than September 30, 2019.Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* MM DD YYYY Do you currently have dental insurance?*YesNoWho is your dental insurance with?*How many people reside in your household?*Please enter a value greater than or equal to 1.What is your annual household income?**$0 - $36,420$36,420 - $49,380$49,380 - $62,340$62,340 - $75,300$75,300 - $88,260$88,260 - $101,220$101,220 - $114,180$114,180 - $127,140$127,140 and aboveAre you currently missing a tooth?*YesNoWhere are you missing teeth?* In the Back on the Upper Right In the Back on the Upper Left In the Back on the Lower Right In the Back on the Lower Left In the Front on Top In the Front on the Bottom In 150 words or less, please tell us why you think you would be a good candidate for this program.**Applicants who are selected must sign a Statement of Eligibility during their appointment to confirm that their household income falls within the selection criteria. The Smiles for Everyone Foundation reserves the right to request supporting documentation for the information provided in this form. Submission of this form does not guarantee participation in any of the Smiles for Everyone Foundation's programs or constitute any obligation on the licensed parties. By clicking "Submit" I acknowledge that the information provided is true and accurate and that I am not related to or affiliated with an individual that serves as a director or officer of the Smiles for Everyone Foundation, Smile Brands Inc. PCs, or any affiliated dental group.