Arizona Dentist Membership Application
= Required Fields)
(First Middle Last)
(To help us pronounce your name when we give referrals)
ADA Member Number
Arizona Dental License
Date of Birth
(We do not share/publish member email addresses)
Preferred Mailing Address:
This Address Is
This Address Is
This Address Is
Social Media for your Office:
Please indicate ADA-reconignized specialty you are limited to
Post Graduate Training
I HEREBY APPLY for membership in the American Dental Association, Arizona Dental Association and my local dental society and resolve to abide by the
Constitution and Bylaws
Principles of Ethics and Code of Professional Conduct
Peer Review Program
of each organization, if elected for membership.
I CERTIFY THAT all statements made by me in this application are complete, true and honest. I understand and agree that if any statement is found to be false or omitted, this application may be rejected solely for that reason. I also understand and agree that in the event such false statement(s) or omission(s) does not become known to the Dental Society until after I have been elected, I understand my membership may be terminated immediately on the basis of incomplete or false information. For the purposes of this paragraph, I understand that a material misstatement or omission shall mean, one which is "significant in relation to the questions asked to which the false statement or to which the omission was made."
I FURTHER AGREE that I will recognize the authorized officers of my local dental society and said Association as the proper and sole authorities to interpret all areas of professional conduct and interpretations.
UPON BECOMING A MEMBER of the local dental society, Arizona Dental Association and the American Dental Association, I hereby waive the right to hold this society, the Association or any member thereof, responsible for any damage in case of disciplinary action involving me, after a hearing in accordance with the Bylaws of this society, the Arizona Dental Association and the American Dental Association.
I have read and understand the above membership agreement.
I was referred/recruited to membership by Dr.
The Arizona Dental Association provides approximately 500 patient referrals each week. So that we can provide the most up-to-date information about your practice, please check each service your dental office provides.
(Radiation & Chemo Therapy)
Children 0-5 yrs old
Nursing Home Calls
Please indicate the coucils/committes on which you have interest in serving.
Donated Dental Services
New Dentist Activities
Tell us about your occupation:
Tell us about your practice setting:
Owner Private Practice
Non-Owner Group Practice
Full-time Practice 30+ hrs
Dental School Faculty
Other Federal Service
In a Graduate Program
Non Longer in Practice
In an effort to "go green", you have the option to receive the following materials electronically or printed. Please indicate how you would like to receive the following materials.
Annual Membership Directory
What challenges in particular are you encountering in your practice/career?
How can we help?
What is the most valuable benefit the Association provides or should provide?
Note: As a member, you can login to the "Members Area" of this website to update this information if it changes.