New Mexico Dental Journal

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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 Bylawsand thePrinciplesof
Ethics andCodeofProfessionalConduct 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 BylawsandPrincipalsofEthicsandCodeofProfessionalConduct
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. $
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 toJADA,$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.
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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
greger@aldaonline.org
www.aldaonline.org
AlaskaDentalSociety
907.563.3003
800.478.4675*
Fax:907.563.3009
info@akdental.org
www.akdental.org
ArizonaDental
Association
480.344.5777
800.866.2732
Fax:480.344.1442
azda@azda.org
www.azda.org
ArkansasState
DentalAssociation
501.834.7650
800.501.2732
Fax:501.834.7657
info@arkansasdentistry.org
www.arkansasdentistry.org
CaliforniaDental
Association
800.232.7645*
Fax:916.498.6177
membership@cda.org
www.cda.org
ColoradoDental
Association
303.740.6900
800.343.3010
Fax:303.740.7989
info@cdaonline.org
www.cdaonline.org
ConnecticutState
DentalAssociation
860.378.1800
Fax:860.378.1807
jdenneh@csda.com
www.csda.com
DelawareState
DentalSociety
302.368.7634
Fax:302.368.7669
dedeltasociety@gmail.com
www.delawarestate
dentalsociety.org
DistrictofColumbia
DentalSociety
202.547.7613
Fax:202.546.1482
info@dcdental.org
www.dcdental.org
FloridaDental
Association
850.681.3629
800.877.9922
Fax:850.561.0504
fda@floridadental.org
www.floridadental.org
GeorgiaDental
Association
404.636.7553
800.432.4357*
Fax:404.633.3943
phillips@gadental.org
www.gadental.org
HawaiiDentalAssociation
808.593.7956
800.359.6725
Fax:808.593.7636
hda@hawaiidental
association.net
www.hawaiidental
association.net
IdahoState
DentalAssociation
208.343.7543
800.932.8153*
Fax:208.343.0775
info@isdaweb.com
www.isdaweb.com
IllinoisState
DentalSociety
217.525.1406
800.475.4737*
Fax:217.525.8872
info@theisds.org
www.theisds.org
IndianaDental
Association
317.634.2610
800.562.5646
Fax:317.634.2612
contact@indental.org
www.indental.org
IowaDentalAssociation
515.986.5605
800.828.2181
Fax:515.986.5626
info@iowadental.org
www.iowadental.org
KansasDental
Association
785.272.7360
800.432.3583
Fax:785.272.2301
kevin@ksdental.org
www.ksdental.org
KentuckyDental
Association
502.489.9121
800.292.1855
Fax:502.489.9124
mike@kyda.org
www.kyda.org
LouisianaDental
Association
225.926.1986
800.388.6642
Fax:225.926.1886
info@ladental.org
www.ladental.org
MaineDentalAssociation
207.622.7900
800.369.8217
Fax:207.622.6210
info@medental.org
www.medental.org
MarylandState
DentalAssociation
410.964.2880
800.766.2880*
Fax:410.964.0583
mddent@msda.com
www.msda.com
Massachusetts
DentalSociety
800.342.8747
Fax:508.480.0002
madental@massdental.org
www.massdental.org
MichiganDental
Association
517.372.9070
800.589.2632*
Fax:517.372.0008
membership@
michigandental.org
www.smilemichigan.com/
pro
MinnesotaDental
Association
612.767.8400
800.950.3368
Fax:612.767.8500
info@mndental.org
www.mndental.org
MississippiDental
Association
601.664.9691
Fax:601.664.9796
office@msdental.org
www.msdental.org
MissouriDental
Association
573.634.3436
800.688.1907
Fax:573.635.0764
info@modental.org
www.modental.org
MontanaDental
Association
406.443.2061
800.257.4988*
Fax:406.443.1546
mda@mt.net
www.mtdental.com
NebraskaDental
Association
402.476.1704
888.789.2614*
Fax:402.476.2641
nda@windstream.net
www.nedental.org
NevadaDental
Association
702.255.4211
800.962.6710
Fax:702.255.3302
anthony.ferreri@nvda.org
www.nvda.org
NewHampshire
DentalSociety
603.225.5961
800.244.5961*
Fax:603.226.4880
info@nhds.org
www.nhds.org
New Jersey
DentalAssociation
732.821.9400
800.831.6532*
Fax:732.821.1082
ameisel@njda.org
www.njda.org
NewMexico
DentalAssociation
505.294.1368
888.589.6632
Fax:505.294.9958
mmoores@nmdental.org
www.newmexicodental.org
NewYorkState
DentalAssociation
518.465.0044
800.255.2100*
Fax:518.465.3219
info@nysdental.org
www.nysdental.org
NorthCarolina
DentalSociety
919.677.1396
800.662.8754
Fax:919.677.1397
ncds@ncdental.org
www.ncdental.org
NorthDakota
DentalAssociation
701.223.8870
800.795.8870
Fax:701.223.0855
ndda@midconetwork.com
www.nddental.com
OhioDentalAssociation
614.486.2700
800.282.1526
Fax:614.486.0381
dentist@oda.org
www.oda.org
OklahomaDental
Association
405.848.8873
800.876.8890
Fax:405.848.8875
membership@okda.org
www.okda.org
OregonDental
Association
503.218.2010
800.452.5628*
Fax:503.218.2009
members@oregondental.org
www.oregondental.org
PennsylvaniaDental
Association
717.234.5941
800.223.0016
Fax:717.234.4301
ckc@padental.org
www.padental.org
ColegiodeCirujanos
DentistasdePuertoRico
787.764.1969
Fax:787.763.6335
administrador@ccdpr.org
www.cpdpr.org
Rhode Island
DentalAssociation
401.825.7700
Fax:401.825.7722
melanie@ridental.com
www.ridental.com
SouthCarolina
DentalAssociation
803.750.2277
800.327.2598*
Fax:803.750.1644
Lathamp@scda.org
www.scda.org
SouthDakota
DentalAssociation
605.224.9133
Fax:605.224.9168
info@sddental.org
www.sddental.org
TennesseeDental
Association
615.628.0208
800.824.9722*
Fax:615.628.0214
tda@tenndental.org
www.tenndental.org
TexasDentalAssociation
512.443.3675
Fax:512.443.3031
rachael@tda.org
www.tda.org
UtahDentalAssociation
801.261.5315
800.662.6500
Fax:801.261.1235
uda@uda.org
www.uda.org
VermontState
DentalSociety
802.864.0115
800.640.5099*
Fax:802.864.0116
info@vsds.org
www.vsds.org
Virgin Islands
DentalAssociation
340.777.6612
Fax:340.777.6128
drbruceshrallow@
yahoo.com
VirginiaDental
Association
804.288.5750
800.552.3886*
Fax:804.288.1880
dickinson@vadental.org
www.vadental.org
WashingtonState
DentalAssociation
206.448.1914
800.448.3368
Fax:206.443.9266
info@wsda.org
www.wsda.org
WestVirginia
DentalAssociation
304.344.5246
Fax:304.344.5316
wvrds@aol.com
www.wvdental.org
WisconsinDental
Association
414.276.4520
800.364.7646
Fax:414.276.8431
info@wda.org
www.wda.org
WyomingDental
Association
307.237.1186
800.244.0779
Fax:307.237.1187
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DepartmentofMembership Information
211EastChicagoAvenue,Chicago, Illinois60611
T312.440.2607 800.621.8099 ADA.org
TripartiteMembershipApplication
Formembership in theAmericanDentalAssociationand
your stateand localdental societies
To download a membership application go to
and click on the Join Now and Download the Tripartite Membership (PDF) .
TODAY
714 Dentists Statewide
6 Local Districts
– Sante Fe
– Albuquerque
– Eastern
– Northwest
– Southwest
– West Central
Please send your completed application to:
Kansas K. Begaye, NMDA Director of Membership
9201 Montgomery Blvd NE, Ste 601, Albuquerque, NM 87111
505-294-1368 | Fax 505-294-9958 |