membership

Membership Form

Membership Form

Thank you for your interest in becoming a member of organized dentistry. The American Dental Association, Pennsylvania Dental Association and the Dental Society of Western Pennsylvania have a tripartite membership structure. Therefore, final approval of your application provides you with membership at all levels of your professional association: local, state, and national. If you are a tripartite member in another district and are moving to the Western Pennsylvania area, your membership can be transferred.

Name

Sex

Dental School

Degree *

Home Address

Primary Offiice Address

Advanced Education Program

Program Area(s): *

Is your practice limited to the above specialty?

Additional Information

Please indicate if you are:

Please indicate if you are practicing or interested in practicing:

Are you practicing full time or part time?

Sponsored by (sponsorship is not required for membership):

Please indicate if licensed:

Are / were you a member of the American Student Dental Association?

Are you interested in voluteering?