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Tripartite Membership Application
 

Thank you for your interest in becoming a member of organized dentistry. The American Dental Association and your state and local 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, state and national. Your application will be processed and considered by your state or local 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 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 see our website www.ada.org/ada/governance/index.asp.

Please complete all sections of this application.
* Indicates required field.
PERSONAL
             
Degree:*   DMD DDS   OTHER  
ADA Number:          
Firstname:*   Lastname:*  
Middle Name:     Alias/Maiden:  
Primary Office            
Street:*     Date of birth:  
City:*         Sex: M F
State:*     County:  
Zip Code:*     Suite#:  
Phone:     Fax:  
Email:*     Mail to Preference:* Office Home
Home Address            
Street:     Unit #:  
City:     State:  
Zip Code:          
Email:     County:  
Phone:     Fax:  
Spouse Info            
Firstname:   Lastname:  
Middlename:     Alias/Maiden:  
             
Spouse a Dentist?   Y N   ADA Member Referral Name:  
        ADA Member Referral State:  

BIOGRAPHICAL            
             
Dental School:*      
Country:*          
Graduation Date :* (mm/dd/yyyy)   Certificate/Degree:  
Advanced Education Program:   Completion Date :   (mm/dd/yyyy)
Do you have a degree or certificate in an ADA recognized specialty?:   N Y (check below)
Endodontics Pediatric Dentistry Periodontics Public Health Prosthodontics Oral & Maxillofacial Pathology Oral & Maxillofacial Radiology Oral & Maxillofacial Surgery Orthodontics and Dentofacial Orthopedics
Is your practice limited to one of the above specialties?: N Y 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:     ZipCode:  
State:     Presently Licensed?   N Y (check below)
If licensed please list license number,s), date, year and state(s). Please indicate specialty license information if applicable.
 

PERSONAL BACKGROUND
             
Have you ever been denied a dental license?:* N Y (if yes, what state?)  
If yes, why?:          
Have you ever had your license suspended or revoked?:* N Y (if yes, state?)  
If yes, why?:          
Have you ever been censored, suspended or expelled by a dental related organization (i.e., dental society)?:* N Y (if yes, what 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.):* N Y
If yes, please describe below (include dates, offenses and penalties):

APPLICATION SIGNATURE
I hereby apply for tripartite membership in the American Dental Association and resolve to abide by the Bylaws and Principles of Ethics and Code of Professional Conduct if accepted into membership.
       
Signed:* Date: (mm/dd/yyyy)

TO BE COMPLETED BY SOCIETY
 
CONSTITUENT SOCIETY
Date received ________ / ___________ / ___________ Date approved or disapproved ___________________
Approval signature _____________________________ Approval name _______________________________
 
COMPONENT SOCIETY
Date received ________ / ___________ / ___________ Date approved or disapproved ___________________
Approval signature _____________________________ Approval name _______________________________
 
DUES SECTION
ADA $________________ Method of payment ______________________________
Constituent $________________ Credit card number ______________________________
Misc $________________ Expiration date ________ / ___________ / _________
Misc $________________ Name on credit card ______________________________
Component $________________    
Total Dues Owed $________________    

A listing of state dental societies is available on our website at www.ada.org or you may contact the ADA Department of Membership Information 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 2009, 9.0% of a member's ADA dues paid are to be allocated to lobbying activities ($48.00 for members paying the full active dues and assessments of $498.00.) Dues payments and contributions are not deductible as charitable contributions for federal income tax purposes.
       
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