Application For Membership

I hereby apply for membership in the Delaware State Dental Society and the American Dental Association. (A membership application fee of $25 must be submitted with this form.)

I am applying for: Active
Life
Student
Honorary
Affiliate
Associate
Retired
Name (last, first, middle initial)
Main Office Address
Phone Number
Fax Number
Email Address
Home Address
Home Phone Number
Date of Birth
Sex
Social Security Number
Marital Status
Spouse's Full Name
Dental School
Degree
Year
DE License Number
Date of DE License
Also Licensed to Practice in (list states)
Specialty
Year of Eligibility
Year Certified
Type of Practice (General or Specialty)
ADA Number
DE Anesthesia Permit No.
DE DEA Number
Were you a member of the American Student Dental Association at the time of your graduation? YES | NO
Internship/Dates
Residency/Dates
Full Time Graduate Study/Dates
Military Service/Dates
List any current hospital or school affiliations or positions
Do you have any dental lawsuits pending? If Yes, please explain:
Have you ever been a member of the ADA? YES | NO
If yes, give dates: From To
Previous State Society
Previous Component Society

If elected into membership, I promise to abide by the Constitution and Bylaws and Code of Ethics of the American Dental Association and the Delaware State Dental Society.

By checking the box below, I hereby affirm that all of the information above is accurate and correct to the best of my ability, and that I am the person listed below, and by typing in my name and date, I am effectively "signing" this document.

Type Your Name: Date:

 


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