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Charlotte Dental Society Membership Application

Application Date:
Name:
Birth Date:
Practice Name:
Specialty:
Office Address:
Office Phone:
-
Fax:
-
E-mail:
Website:
Home Address:
Home Phone:
-
Spouse's Name:
Spouse's Employment:

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, $225.00; 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,  $225.00; 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:
Membership Status:
ADA #:

EDUCATION:

Undergrade, Degree, Year:
Undergrade, Degree, Year:(1)
Dental, Degree, Year:
Other, Degree, Year:
State License #, Date:

Sponsorship

Applicants for active and associate membership must have the signature  recommendations of two active members of the Charlotte Dental Society. 

Name and phone numbers for TWO ACTIVE Members.

Please complete the following and return with your membership application to the Charlotte Dental Society office:  1112 Harding Place #200, Charlotte, NC 28204. Phone: (704) 376-6555 – FAX: (704) 376-3173.  Thank you for your cooperation. 


Additional Information

Name
Board Certification:
Hospital Privileges:
Foreign Language(s):

Referral Information  

The Mecklenburg County Medical Society and The Charlotte Dental Society provide a medical and dental telephone referral service for the benefit of the community.  This line, 704-376-0847, is open from 9:00 am to 1:00 pm Monday through Friday and is operated by staff members of MCMS and CDS.  It is listed in the Yellow Pages of the telephone directory and is provided at no charge to members.   Please complete the following to assist the CDS staff in maintaining an effective referral service. 

I will accept referrals for:
I accept the following payment options:

The most frequent request made regarding the availability of dental services is for the names of dentists who accept Medicaid.  The dental society office provides a recorded message with the names and phone numbers of those dentists.  To access this recording, patients should call the medical/dental referral line, 704-376-0847, between 9:00 am and 1:00 pm Monday through Friday.  If you accept Medicaid, would you be willing to have your name and phone number included on this recording? 

Choose one:

VOLUNTEER INFORMATION  

I am interested in serving as a member of the following standing committees: 

Choose all that apply:

New Member Profile - Personal Information

Your Name:
Nickname:
Hobbies and Recreational Activities:
Spouse's Hobbies:
Children's Names and Ages:
Comments:
Word Verification:

Thank You!

Charlotte Dental Society