39 May 18–20, 2023 2023 Fiesta NMDA Register online at www.nmdental.org 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 and local dental society (where applicable) Personal Background Have you ever been denied a dental license? Yes No If yes, in which state: If yes, why? Have you ever had your license suspended or revoked? Yes No If yes, in which state: If yes, why? Have you ever been censored, suspended or expelled by a dentally related organization (i.e. dental society)? Yes No If yes, in which state: If yes, why? Have you ever been convicted of a felony or criminal offense, including driving under the influence of alcohol or drugs, but excluding minor traffic violations and parking tickets? (A conviction record will not automatically bar you from membership. Each application will be individually considered on its merits.) Yes No If yes, please describe (include dates, offenses and penalties): Applicant Signature I hereby apply for a tripartite membership in the American Dental Association and resolve to abide by the Bylaws and Principals of Ethics and Code of Professional Conduct if accepted into membership. If I have paid by credit card below*, my signature authorizes payment. Review the bylaws and code at ADA.org/ethicsconduct. Signature Date (MM/DD/YYYY) *Your society will contact you if payment is required. Do not send payment now. To Be Completed By Society: Constituent Society Date Received (MM/DD/YYYY) Approval Name Date Approved or Disapproved (MM/DD/YYYY) Approval Signature Component Society Date Received (MM/DD/YYYY) Approval Name Date Approved or Disapproved (MM/DD/YYYY) Approval Signature Dues Section ADA $ Method of Payment Visa MasterCard American Express Constituent $ Misc. $ Credit Card Number Misc. $ Expiration Date (MM/YY) Security Code Component $ Name on Credit Card Total Dues Owed $ Please submit your completed 2-page application to your state or local dental society. A listing of state dental societies is available on our website at ADA.org or you may contact the ADA Department of Membership Operations at 312.440.2607 for more information. Membership in the ADA is based on the calendar year from January to December. ADA dues allocation to JADA, $25.00, to ADA News, $8.00, and is not deductible from the dues amount. United States Taxpayers Please Note: The tax law prohibits taxpayers from deducting the expenses that they incur by engaging in lobbying, as defined in the law. Accordingly, only that portion of an associations’ member’s dues not attributable to lobbying activities remains deductible as an ordinary and necessary business expense. The law requires associations to provide their members with a reasonable estimate of the non-deductible percent of their dues attributable to lobbying activities. For 2019, 7% of a member’s ADA dues are allocated to lobbying activities. Dues payments and contributions are not deductible as charitable contributions for federal income tax purposes. 9201 Montgomery Blvd NE Ste 601 Albuquerque NM 87111 T 505-294-1368 F 505-294-9958 www.nmdental.org (2 of 2)
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