PAGD Keystone Explorer Winter 2019 20

DUES INFORMATION Please check membership type applying for: U.S./ Canada ¨ Active General International (in Canadian dollars) Puerto Rico Dentist ...................................... $400 ............................ $443 ............................... $324 ¨ Associate ................................... 400 .............................. 443 .................................. 324 ¨ Affiliate ........................................ 200 .............................. 221 .................................. 162 ¨ Resident ........................................ 80 ................................. 89 ..................................... 65 ¨ 2018 Graduate .......................... 80 ................................. 89 ..................................... 65 ¨ 2017 Graduate ....................... 160 .............................. 177 .................................. 130 ¨ 2016 Graduate ....................... 240 .............................. 266 .................................. 194 ¨ 2015 Graduate ....................... 320 .............................. 354 .................................. 259 ¨ Dental Student .......................... 20 ................................. 22 ..................................... 20 1. AGD Headquarters Dues: .................................................................... $________ 2. AGD Constituent Dues: ........................................................................ $________ 3. AGD Component Dues: ........................................................................ $________ Please refer to back side for constituent and component dues. Total Amount Enclosed: ............................................................... $________ Dues rates effective through September 30, 2019. 2019 AGD Membership Application Join online at agd.org, or call us at 888.243.3368 or 312.440.4300. MEMBER INFORMATION First name MI Last name Designation Date of birth (mm/dd/yyyy) (e.g. DDS, DMD, BDS) Required for access to the members-only sections of the AGD website Do you currently hold a valid U.S./Canadian dental license? ¨ No ¨ Yes: ________________________________________________________________________ License number State/province Date renewed (mm/yyyy) Type of membership: (Check one.) ¨ Active general dentist ¨ Associate (dental specialist) ¨ Resident ¨ Dental student ¨ Affiliate If you are not in general practice, please indicate your specialty: __________________________________________________________________________________ Current dental practice environment: (Check one.) ¨ Solo ¨ Associateship ¨ Group practice ¨ Hospital ¨ Resident ¨ Corporate ¨ Other ____________________________________ ¨ Faculty ___________________________________ ¨ Federal Services ___________________________ Please indicate institution Please indicate branch If you are a member of the Canadian Forces Dental Service, please indicate your preferred constituent: ¨ U.S. military counterpart ¨ Local Canadian constituent CONTACT INFORMATION Preferred billing/mailing address: ¨ Business ¨ Home Your AGD constituent is determined by your business address, unless one is not available. Preferred method of contact: ¨ Email ¨ Mail ¨ Phone Business address City State/province ZIP/postal code Name of business (If applicable) Phone Fax Home address City State/province ZIP/postal code Phone Primary email Website address EDUCATIONAL INFORMATION Are you a graduate of an accredited* U.S./Canadian dental school? ¨ Yes ¨ No ¨ Currently enrolled Dental school State/province Country Date of graduation (mm/yyyy) Are you a graduate of (or resident in) an accredited** U.S. or Canadian postdoctoral program? ¨ Yes ¨ No ¨ Currently enrolled Type: ¨ AEGD ¨ GPR ¨ Other Postdoctoral institution State/province Country Start date (mm/dd/yyyy) End date (mm/dd/yyyy) OPTIONAL INFORMATION Gender: ¨ Male ¨ Female Ethnicity: ¨ American Indian ¨ Asian ¨ African-American ¨ Hispanic ¨ Caucasian ¨ Other I am interested in participating in the AGD Mentor Program as a: ¨ Mentor ¨ Mentee *Official accreditation is given by CODA in the U.S. and CDAC for all Canadian provinces. **Accredited dental residencies qualify for the resident membership rate. Official proof of enrollment must be provided to AGD. I hereby certify that all of the above information is correct, and that by signing this application, I agree to all terms of membership including completion of 75 hours of continuing education every three years for active general dentist and associate members. Signature Date Please sign this application and submit payment to: Academy of General Dentistry 560 W. Lake St., Sixth Floor Chicago, IL 60661-6600 Note: Check payment is required with hard copy applications. To pay with credit card, please apply online at agd.org/join-agd. If you have any questions, please contact our Membership Services Center at 888.243.3368. Stay Social With the AGD! Search “Academy of General Dentistry” to connect with us on: REFERRAL INFORMATION If you were referred to the AGD by a current member, please note his or her information below: Member’s name City, state/province, or U.S. Federal Services branch PROMOTIONAL CODE : _______________