Application For Membership

I hereby apply for membership in the Delaware State Dental Society and the American Dental Association.

Fields marked with * are required for form submission.

I am applying for: * Active
Life
Student
Honorary
Affiliate
Associate
Retired
Name
First * MI Last *
Main Office Address
Street Address *
City * State * Zip *
Phone Number *
Fax Number
Email Address *
Home Address
Street Address *
City * State * Zip *
Home Phone Number *
Date of Birth *
Sex *
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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Delaware State Dental Society
892 Eichele Road
Perkiomenville, PA 18074-9510
Phone: 302-368-7634
Email:
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