Student Member Transfer Application

Student members should submit this application to transfer member categories after the end of their postdoctoral training.

Eligibility Requirements, Benefits, and Dues for Member Categories

Members Only Content:

Member Only

I wish to transfer to the following member category: *

Active

Associate

International

Name: *

Member Number: *

MY CONTACT INFORMATION

Some of my contact info below has been changed or added.

Street Address: *

City: *

State / Province:

Zip / Postal Code:

Country: *

Phone: *

Fax:

Email: *

Website:

PROFESSIONAL INFORMATION

Place of Licensure: *

Dental License Number *

Perio Training Institution: *

Training Completed in: *

My Practice Is Limited to: *

Professional Organization: *

Membership Number: *

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

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. 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.