Membership Application

Mr.    Ms.    Mrs.   Dr.  
Last Name:
Degree:
Nickname:
Spouse's Name:
CAD/CAM User?   Yes    No
                           CEREK E4D
What percentage of your practice is devoted to CAD/CAM dental procedures?
 
The following will be used for the ACCD webiste Member's referral links:
Business Information:  
Business/Practice Name:  
Business Address:  
City:   State:    Zip:   Country:
Business Phone: Business Fax:
E-mail Address: Website URL for Referral Listing:
Personal Information:  
Home Address:  
City:   State:   Zip:    Country:

Home Phone:

Home Fax:
Date of Birth:  
 
   
What year did you begin practicing dentistry?
Specialty:
Have you previously been a member of the ACCD (ACADNA)? Yes    No
If yes, when?
Dental/Medical Education: Graduate Education:
Institution: Institution:
Degree: Degree:     
Year: Year:          
Postgraduate Education: University Affilitation
Institution: (Teaching or Research):
Degree:  
Year:  
   
Are you a member of the ADA? Yes    No
 
Are you a member of the AGD? Yes    No
 
Other National Dental Associations:

In what states, provinces, or countries are you licensed in?
Other Affiliations: (Hospitals, Government, Military, etc.)
Publications and Presentations:
Participation in Professional Organizations: (Include offices and committee chairmanships)
I am interested in the following:  
Conference Committees Technology Committees
Board Positions Local Chapters
Meeting Hospitality Host New Members Committee
Industry Partners Committee Publications Committee
   
Membership Dues:  
$365.00
Team/Staff $300.00
Student/Resident $200.00
Corporate/Industry $750.00
   
* Additional documentation will be required to maintain member status for all categories with reduced rates.

* Student category - please supply a copy of a dated letter of admission into an education program or a photocopy of your current student ID.

* Resident category - please supply a copy of a dated letter from Residency program. The letter should include your residency start and end dates.
   
   
 
I agree to the terms/conditions refund policy.
   
 

 

 
 

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