New Mexico Dental Journal

nmdental.org

The American Dental Association, the New Mexico Dental Association

and local 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 the

New Mexico Dental Association.

Please let us know if you need additional information regarding our

application procedures, membership dues or the Bylaws and the

Principles of Ethics and code of Professional Conduct of the ADA

and the New Mexico Dental Society, which govern the professional

conduct of members.

Become a

As the premiere dental association in the state, the NMDA is responsible for

advocating for the art and science of dentistry on behalf of the people of New Mexico.

Member

DepartmentofMembership Information

211EastChicagoAvenue,Chicago, Illinois60611

T312.440.2607 800.621.8099 ADA.org

TripartiteMembershipApplication

Formembership in theAmericanDentalAssociationand

your stateand localdental societies

Thankyou foryour interest inbecomingamemberoforganizeddentistry.

TheAmericanDentalAssociation andyour state and localdental societieshave a tripartitemembership structure.Therefore, final approvalofyour applicationprovides

youwithmembership at all three levelsofyourprofessional associations: local, state andnational.Your applicationwillbeprocessed and consideredbyyour stateor local

society,whichwillprovideyouwith additional information regarding their specific applicationprocedures.Please apply to the societywhereyou conductorwill conduct

themajorportionofyourpractice;your stateor local societymay request additional information. For complete information regarding the

Bylaws

and the

Principlesof

Ethics

and

CodeofProfessionalConduct

of theADAwhichgovern theprofessional conductofmembers,pleasevisitADA.org/constitutionbylaws.A listof statedental

societies accompanies this application.

Pleasecompleteall sectionsof thisapplication.Printor typeall information.

Personal Information

Name

(First) (Last) (Middle)

Male Female

ADA IDNumber (if known)

DateofBirth

(MM/DD/YYYY)

PrimaryOfficeAddress

Suite

City

State

Zip

Phone

(include area code)

EmailAddress

Fax

(include area code)

HomeAddress

Phone

(include area code)

City

State

Zip

Please indicate ifyouprefer

tohavemail sent to:

Home Office

Please indicate ifyouprefer

tohaveemail sent to:

Home Office

EmailAddress

Spouse’sName (optional)

(First) (Last) (Middle) (Alias/Previous/Maiden)

Is spouse adentist? Yes No

If anADAmemberencouragedyou to join,please indicate:

Name

State

Biographical

DentalSchool

Country

GraduationDate

(MM/DD/YYYY)

AdvancedEducationProgram

(if applicable)

CompletionDate

(MM/DD/YYYY)

Certificate/

Degree

Doyouhave adegree in anADA recognized specialty? Yes No

Ifyes,which specialty?

Endodontics

PediatricDentistry

Periodontics

PublicHealth

Prosthodontics

Orthodontics andDentofacialOrthopedics

Oral&MaxillofacialPathology

Oral&MaxillofacialRadiology

Oral&MaxillofacialSurgery

Isyourpractice limited tooneof the above specialties? Yes No

Ifyes,which specialty?

Some societiesofferassistance in locatingapractice situation.

Contact your localdental society for information regarding their services.

Please indicate ifpracticing in,or looking for:

Solo

Group

Partnership

Associateship

Clinic

Faculty

FederalDentalService

Other:

Ifpracticing inother thana solopractice,please indicate thegrouporpractitioner’snameand location.

Name

Street

City

State

Zip

Please indicate if licensed:

Presently Licensepending

If licensed,please list licensenumber(s),date,year and state(s).Please indicate specialty license information if applicable.

(1of3)

TRIP 02/12

DepartmentofMembership Information

211EastChicagoAvenue,Chicago, Illinois60611

T312.440.2607 800.621.8099 ADA.org

TripartiteMembershipApplication

Formembership in theAmericanDentalAssociationand

your stateand localdental societies

PersonalBackground

Haveyoueverbeendenied

adental license?

Yes No

Ifyes, inwhich state:

Ifyes,why?

Haveyoueverhadyour license

suspendedor revoked?

Yes No

Ifyes, inwhich state:

Ifyes,why?

Haveyoueverbeen censored,

suspendedorexpelledby a

dentally relatedorganization

(i.e.dental society)?

Yes No

Ifyes, inwhich state:

Ifyes,why?

Haveyoueverbeen convicted

of a felonyor criminaloffense,

includingdrivingunder the

influenceof alcoholordrugs,

butexcludingminor traffic

violations andparking tickets?

(A conviction recordwillnot automati-

callybaryou frommembership.Each

applicationwillbe individually considered

on itsmerits.)

Yes No

Ifyes,pleasedescribe (includedates,offenses andpenalties):

ApplicantSignature

Ihereby apply for a tripartitemembership in theAmericanDentalAssociation and resolve to abideby the

Bylaws

and

PrincipalsofEthicsandCodeofProfessionalConduct

if accepted intomembership. If Ihavepaidby credit cardbelow*,my signature authorizespayment.Review thebylaws and code atADA.org/constitutionbylaws.

Signature

Date

(MM/DD/YYYY)

*Your societywill contactyou ifpayment is required.Donot sendpaymentnow.

ToBeCompletedBySociety:

Constituent

Society

DateReceived

(MM/DD/YYYY)

ApprovalName

DateApprovedorDisapproved

(MM/DD/YYYY)

ApprovalSignature

Component

Society

DateReceived

(MM/DD/YYYY)

ApprovalName

DateApprovedorDisapproved

(MM/DD/YYYY)

ApprovalSignature

DuesSection

ADA

MethodofPayment

Visa MasterCard AmericanExpress

CreditCardNumber SecurityCode

ExpirationDate

(MM/DD/YYYY)

NameonCreditCard

Constituent

Misc.

Component

TotalDuesOwed

Please submityourcompleted2-pageapplication toyour stateor localdental society.A listingof statedental societies is availableonourwebsite atADA.orgoryoumay contact theADADepartmentofMembership

Information at312.440.2607 formore information.

Membership in theADA isbasedon the calendaryear from January toDecember.ADAdues allocation to

JADA

,$25.00, to

ADANews

,$8.00, and isnotdeductible from thedues amount.

UnitedStatesTaxpayersPleaseNote:The tax lawprohibits taxpayers fromdeducting theexpenses that they incurbyengaging in lobbying, asdefined in the law.Accordingly,only thatportionof an associations’member’s

duesnot attributable to lobbying activities remainsdeductible as anordinary andnecessarybusinessexpense.The law requires associations toprovide theirmemberswith a reasonableestimateof thenon-deductiblepercent

of theirdues attributable to lobbying activities. For2012,8.8%of amember’sADAdues are allocated to lobbying activities ($45.00 formemberspaying the full activeduesof$512.00).Duespayments and contributions

arenotdeductible as charitable contributions for federal income taxpurposes.

(2of3)

TRIP 02/12

ADAStateDentalSocieties

*intra-statecallsonly

Note: state societies are also called constituent state societies. For themostup todate listof state contact information,visitADA.org/societydirectories

AlabamaDental

Association

334.265.1684

800.489.2532

Fax:334.262.6218