AAP Membership Application

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Complete and submit this form to apply for membership. Annual dues are for the calendar year January 1 to December 31. Applications received on or after October 31 are processed with a join date of January 1 the following year.

Benefits and Eligibility Requirements for Member Categories

Members Only Content:

Not Member Only

Membership category you are applying for: *

Active Membership ($890 annual dues in 2013, $200 application fee)

Associate Membership ($890 annual dues in 2013, $150 application fee)

International Membership ($445 annual dues in 2013, $50 application fee)

Student Membership ($117 annual dues in 2013, no application fee)

NOTE: Application fee is waived for past members.

PERSONAL INFORMATION

First Name: *

Middle Name or Initial:

Last Name: *

Suffix:

Credentials:

DDS

DMD

Other Credentials:

Date of Birth: *

Gender: *

Male

Female

MAILING ADDRESS

Send AAP Mailings to: *

My Home

My Office

My School

Street Address: *

City: *

State or Province:

Zip/Postal Code:

Country: *

OTHER CONTACT INFORMATION

Phone:

Cell Phone:

Fax:

Email Address: *

Confirm Email Address: *

Required for payment of membership dues and application fee.

Website:

DENTAL SCHOOL & LICENSE

Dental School: *

Degree Earned: *

Year of Graduation: *

Place of Licensure: *

Dental License Number *

POSTDOCTORAL TRAINING

Perio Training Institution:

Required for Active and Student membership.

Perio Program Director:

Date of Periodontal Certification:

Other Specialty Training (if any):

Institution for Other Training:

Date of Other Certification:

PRACTICE & TEACHING

My Practice Is Limited to: *

Teaching appointment:

Yes

Institution Name:

Full- or Part-Time:

Staff of Military or Government Agency:

Yes

Military Branch/Agency Name:

PROFESSIONAL ORGANIZATION & CERTIFICATION

Membership in the American Dental Association is required for U.S. applicants. Membership in a recognized national dental association is required for international applicants.

Organization Name:

Membership Number:

Click here if you are a board-certified Diplomate of the American Board of Periodontology.

Click to Verify: *

I certify that the foregoing information is true and correct to the best of my knowledge. I believe I am eligible for membership in the category requested. If I am elected to membership in the American Academy of Periodontology, I agree to uphold the principles and the objectives of the Academy and abide by its bylaws. I agree further to advise the Academy of any changes in status that would amend or alter the information provided in the application. I understand that a portion of the membership fee is payment for a Journal of Periodontology subscription (U.S. $239 and International $287).

Promotional Code (if applicable):

Referred to AAP by:

What AAP member benefit do you look forward to the most, and why?

Your response will help us to develop member benefits that meet your needs.

Click here if you're willing to have your answer to the preceding question used in future materials on the value of AAP membership.

PAYMENT PROCESS

After you submit your application, a link to pay your membership dues and application fee will be sent to you within one business day at the above email address. Please click the link to go to a secure site for entering your credit-card information. Once we receive your payment, your membership will be activated.

Click to Confirm: *

I understand the above payment process that is required for activation of my membership.