Membership Application | Dental Society

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Charlotte Dental Society Membership Application

Application Date:

Name:

First

Last

Birth Date:

Practice Name:

Specialty:

Office Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Office Phone:

Area Code

Phone Number

Fax:

Area Code

Phone Number

E-mail:

Website:

Home Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Home 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 Associate

Membership Status:

American Dental Association

North Carolina Dental Society

Second Distrct

ADA #:

Word Verification:

Thank You!

Charlotte Dental Society