AzDA - Online Application

Information:

*Full Name	(First Middle Last)
Phonetic Pronunciation	(To help us pronounce your name when we give referrals)
ADA Member Number
*Arizona Dental License
Date of Birth	(mm/dd/yyyy)
Gender	M F
Spouse Name
Email	(We do not share/publish member email addresses)

Preferred Mailing Address:

*This Address Is	Home Office #1 Office #2
*Address
*City	State Zip
*Phone	Fax
Website

Secondary Address:

This Address Is	Home Office #1 Office #2
Address
City	State Zip
Phone	Fax
Website

Alternate Address:

This Address Is	Home Office #1 Office #2
Address
City	State Zip
Phone	Fax
Website

Education:

Please indicate ADA-reconignized specialty you are limited to
General Practitioner Endodontics Pediatric Public Health	Periodontics Prosthodontics Oral Pathology Oral Surgery	Oral Radiology Orthodontics

*Dental School
*Graduation Date	Degree Earned
Internship/Military	From To
Post Graduate Training	From To
Other Training

Membership Agreement:

I HEREBY APPLY for membership in the American Dental Association, Arizona Dental Association and my local dental society and resolve to abide by the Constitution and Bylaws, Principles of Ethics and Code of Professional Conduct and the Peer Review Program of each organization, if elected for membership. I CERTIFY THAT all statements made by me in this application are complete, true and honest. I understand and agree that if any statement is found to be false or omitted, this application may be rejected solely for that reason. I also understand and agree that in the event such false statement(s) or omission(s) does not become known to the Dental Society until after I have been elected, I understand my membership may be terminated immediately on the basis of incomplete or false information. For the purposes of this paragraph, I understand that a material misstatement or omission shall mean, one which is "significant in relation to the questions asked to which the false statement or to which the omission was made." I FURTHER AGREE that I will recognize the authorized officers of my local dental society and said Association as the proper and sole authorities to interpret all areas of professional conduct and interpretations. UPON BECOMING A MEMBER of the local dental society, Arizona Dental Association and the American Dental Association, I hereby waive the right to hold this society, the Association or any member thereof, responsible for any damage in case of disciplinary action involving me, after a hearing in accordance with the Bylaws of this society, the Arizona Dental Association and the American Dental Association. *I have read and understand the above membership agreement.

I was referred/recruited to membership by Dr.

Referral Information:

The Arizona Dental Association provides approximately 500 patient referrals each week. So that we can provide the most up-to-date information about your practice, please check each service your dental office provides.
Bleaching/Whitening Cancer Patients (Radiation & Chemo Therapy) Dental Phobias Dentures Emergencies Evening Hours Financing, Tx	Friday Hours General Anesthesia Hospital Privileges Implants Infant Patients IV Sedations/ Anesthesia Lasers	Latex Allergies Saturday Hours Senior Discounts Sign Language Nitrous Oxide Nursing Home Calls Oral Conscious Sedation	Pediatric Dentistry Special Needs TMJ/TMD Wheelchair Bound Patients Foreign Languages:

Volunteering:

Please indicate the coucils/committes on which you have interest in serving.
Ethics/Peer Review Membership Volunteer Opportunities Communications	Continuing Education Donated Dental Services Dental Health New Dentist Activities	Foundation Activites Legislation Speaker's Bureau Fundraising

Going Green:

In an effort to "go green", you have the option to receive the following materials electronically or printed. Please indicate how you would like to receive the following materials.

General Corespondence	Electronically	Printed
Invoices	Electronically	Printed
Annual Membership Directory	Electronically	Printed
Inscriptions Magazine	Electronically	Printed