San Antonio District Dental Society

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First Name *

Middle Name

Last Name *

Gender *

Male
Female

ADA Number *

Practice Name

Office Address

Office Fax

Office Phone

Home Address *

Home Telephone/Cell *

E-mail Address *

Primary Address * (Office address is used for component society assignment)

Home
Office

Date of Birth *

Spouse's Name

Dental School

Degree

Year of Graduation

Texas Dental License Number (7 digits including 0's)

Year Issued

Licenses held in other states:

Applying as

New Member
Former Member
Grad Student
Transfer

ADA Member

If yes, which state

Speciality

Board Certified

Board Eligible

Year

Practice limited to

Type of Practice

Description of practice (to be included in Member Directory)

Membership in other professional organizations:

I hereby certify that the information contained herein is true and correct and if subsequuently proved incorrect shall be grounds for disapproval and/or removal. I authorize the Component Dental Society membership chairman to seek any information concerning my candidacy for membership in the American Dental Association, the Texas Dental Association and the Component Dental Society and authorize the release of any such information for use in connection with this application to those people who are involved in the membership process.

I certify that I will abide by the Principles of Ethics and Code of Professional Conduct and the Constitution & Bylaws of the ADA, TDA and the Component Society, and that failure to abide by such can result in disciplinary action. I am aware that if my application is not approved, or in the future my membership is rescinded, I can appeal the action.

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General Info

Member

Organization

Resources

Location & Contact