DCDS Associate Membership Application/Renewal

To become a Dallas County Dental Society associate member, you must be a member of another component dental society within the ADA. Please call 972-386-5741 to charge associate dues (see below) to VISA or Master Card or mail check payable to Dallas County Dental Society to: Dallas County Dental Society, 13633 Omega Road, Dallas, Texas 75244.

ADA Number

Last Name

First Name

Middle Name

Preferred Address

City/State

Zip Code

Preferred Phone

Preferred Email

Texas License Number

Year of Issue

Specialty

Select if Applicable

Board Certified
Board Eligible

Year

Specialty

Select if Applicable

Board Certified
Board Eligible

Year

Practice Limited To

Type of Practice

I hereby apply for an associate membership in the Dallas County Dental Society and I will mail or call to pay my annual dues of $250. I certify that I am at present a member in good standing of the American Dental Association.

State Association

Local Society

Please note that dues payments are not deductible as charitable contributions for federal income tax purposes. They may be deductible as ordinary and necessary business expenses to the extent allowable. Dues include a subscription to DCDS Connection, the official publication of Dallas County Dental Society and other local benefits.

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FOR OFFICE USE ONLY
Amount $_______________ Check #_______________ Date Paid_______________

DCDS Associate Membership Application/Renewal

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