AAP Associate Membership Application

Complete and submit this form to apply for membership.

Annual dues are for the calendar year Jan. 1 to Dec. 31. Applications received on or after Oct. 31 are processed with a join date of Jan. 1 the following year.

Associate Membership dues for 2018 are $990 with a $150 application fee.

Benefits and Eligibility Requirements for Member Categories

Note: Application fee is waived for past members.

Members Only Content:

Not Member Only

MAILING ADDRESS

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My Home

My Office

Street Address: *

Street Address 3

Street Address 2

City: *

State or Province:

Zip/Postal Code:

Country: *

OTHER CONTACT INFORMATION

Primary Phone Number: *

This is my (check one)

Office #

Home #

Cell #

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:

Perio Program Director:

Date of Periodontal Certification:

Other Specialty Training (if any):

Institution for Other Training:

Date of Other Certification:

PROFESSIONAL ORGANIZATION & CERTIFICATION

Membership in the American Dental Association is required for U.S. applicants.

Organization Name: *

Membership Number: *

APPLICATION VERIFICATION

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. $273).

ADDITIONAL APPLICATION DETAILS

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.

Permission:

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 three business days 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.

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AAP Associate Membership Application