Click here if you prefer the PDF version. Charlotte Dental Society Membership ApplicationApplication Date:Name: First Last Birth Date:Practice Name:Specialty:Office Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeOffice Phone: Area Code - Phone Number Fax: Area Code - Phone Number E-mail:Website:Home Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeHome Phone: Area Code - Phone Number Membership categories: Active. Member of the dental profession, practicing in Mecklenburg County, licensed according to the dental laws of North Carolina, and member in good standing of the American Dental Society (ADA), the North Carolina Dental Society (NCDS), and the Second District Dental Society. Pay full dues, $275.00; please submit with application. No cost to attend membership meetings. Associate. Member of the dental profession duly licensed to practice in North or South Carolina, practicing outside of Mecklenburg County. Pay full dues, $275.00; please submit with application. No cost to attend membership meetings. New practitioner associate. Member of the dental profession, duly licensed in North Carolina, newly practicing in Mecklenburg County, with or without membership in ADA, NCDS, and Second District. Exempt from dues. Must apply for active membership within 12 months of date of New Practitioner Associate Membership. Membership Category:Active ($275)Associate ($275)New Practitioner AssociateMembership Status:American Dental AssociationNorth Carolina Dental SocietySecond DistrctADA #:Word Verification:SubmitResetThank You!Charlotte Dental Society