Student Member Transfer Application

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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.