38 2023 Fiesta NMDA May 18–20, 2023 New Mexico Dental Association is an ADA CERP Recognized Provider Department of Membership Operations 211 East Chicago Avenue, Chicago, Illinois 60611 T 312.440.2607 800.621.8099 ADA.org Membership Application For membership in the American Dental Association and your state/local/district dental society (where applicable) Thank you for your interest in becoming a member. The American Dental Association and your state and local/district (if applicable) dental societies have a tripartite membership structure. Therefore, final approval of your application provides you with membership at all three levels of your professional associations: local/district, state and national. Your application will be processed and considered by your state or local/district society, which will provide you with additional information regarding their specific application procedures. Please apply to the society where you conduct or will conduct the major portion of your practice; your state or local/district society may request additional information. For complete information regarding the Bylaws and the Principles of Ethics and Code of Professional Conduct of the ADA which govern the professional conduct of members, please visit ADA.org/ethicsconduct. A list of state dental societies can be found at ADA.org/societydirectories. Please complete all sections of this application. Print or type all information. You may also be able to apply online. Please check your state dental society website for instructions. Personal Information Name (First) (Last) (Middle) Male Female ADA ID Number (optional) Date of Birth (MM/DD/YYYY) Website Address Primary Office Address Suite City State Zip Office Phone (include area code) Office Email Fax (include area code) Home Address Mobile Phone (include area code) City State Zip Please indicate if you prefer to have mail sent to: Home Office Please indicate if you prefer to have email sent to: Home Office Home Email Spouse’s Name (optional) (First) (Last) (Middle) (Alias/Previous/Maiden) Is spouse a dentist? Yes No If an ADA member encouraged you to join, please indicate: Name State Biographical Dental School Country Graduation Date (MM/DD/YYYY) Advanced Education Program (if applicable) Completion Date (MM/DD/YYYY) Certificate/ Degree Do you have a degree in an ADA recognized specialty? Yes No If yes, which specialty? Endodontics Pediatric Dentistry Periodontics Public Health Prosthodontics Orthodontics and Dentofacial Orthopedics Oral & Maxillofacial Pathology Oral & Maxillofacial Radiology Oral & Maxillofacial Surgery Is your practice limited to one of the above specialties? Yes No If yes, which specialty? 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 practicing in other than a solo practice, please indicate the group or practitioner’s name and location. Name Street City State Zip Please indicate if licensed: Presently License pending If licensed, please list license number(s), date, year and state(s). Please indicate specialty license information if applicable. (1 of 2) 1/19 9201 Montgomery Blvd NE Ste 601 Albuquerque NM 87111 T 505-294-1368 F 505-294-9958 www.nmdental.org | spate@nmdental.org
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