Friday, 5.9.2008

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Application

 

Learn about member benefits
Read about the enrollment process
 

To expedite processing of your application, please complete all fields that are indicated as required. Additionally, so that we may best serve your needs please complete as many optional fields as possible.

Upon receipt of your application you will be provided with complete information regarding membership dues. You may cancel the application process at any time prior to submitting payment by contacting the ODA at 1-800-282-1526 or by e-mailing membership@oda.org . Once applications are approved and payment is received, refunds are not guaranteed and requests are handled on an individual basis.

Click here if you would like to print out an application form.

Enrollment Form
* FirstName:
* LastName:
* Social Security #: (123-45-6789)
ADA Number: (123-45-6789)
* Birth MM/DD/YY:
* Degree:
DMD DDS Other
Primary Office Address
* Street:
 
* City: * State:
* Zip: (11111)
* County:
* Phone: (123-456-7890)
Fax: (123-456-7890)
Email: (youraddress@yourdomain.com)
Home Address
* Street:
 
* City: * State:
* Zip: (12345)
* County:
* Phone: (123-456-7890) Sex: Male Female
Fax: (123-456-7890)

* Please indicate if you prefer to have mail sent to: Home Office
Spouse Name:  
Is spouse a dentist: Yes no
* Dental School:

* Graduation Date: (MM/YYYY)

Advanced Education Program:(if applicable school/hospital, city/state)
Completion Date: (MM/YYYY)

Certificate / Degree:

Program Areas: (Choose all that apply)
Endo Pediatric Perio Public Health Prostho Ortho Oral Path
Oral Surg General Practice Other:

* Is your practice limited to the above specialty(s): Yes no
Are/Were you a member of the American Student Dental Association ?
Yes, from   To  No

Please indicate:
Currently in a practice
Looking for a new practice opportunity in:

(Some societies offer assistance in locating a practice situation. Contact your local dental society for information regarding their services.)

* Please indicate if practicing in, or looking for:
Solo Group Partnership Associateship Clinic Faculty
Federal Dental Service Other:

If currently practicing please indicate number of staff in practice:
If practicing in other than solo practice, please indicate the group or practitioner's name and location:
Name: Address:
* Please indicate if licensed:
Presently (license number): License Pending
* Please indicate your membership status in the American Dental Association.

New Member

Current Member in

with dues paid for the  membership year

Was previously a member in   and (local society) from 
 to 


By clicking the agree button, I acknowledge that the information I have provided is true to the best of my knowledge. Once membership is approved, I also agree to abide by the Principles of Ethics and Code of Professional Conduct of my local, state, and national associations.

         
 
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