Arizona Allied Membership Application
= Required Fields)
(Hygienist, Dental Assistant, Front Office, etc.)
(We do not give/sell your email address to anyone. This is how we communicate with you.)
At the time of application you are employed by an active or life member of this Association.
Search your dentist here
to make sure.
Or, At the time of application you are a employed faculty member of assisting, hygiene or laboratory technician educational program in Arizona.
Or, At the time of application you are employed by a Federally Qualified Health Center.
(Enter dentists name, not name of business)
Yearly dues of $50 must accompany application.
-- Select Card Type --
Name On Card:
Card Billing Address:
Card Billing Zip Code:
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
(3 or 4 digit code printed on card)
Membership is annual and non-refundable
(Single click to avoid duplicate charges)