Arizona Allied Membership Application


(* = Required Fields)
 
Information:
*First Name     *Last Name 
*Profession (Hygienist, Dental Assistant, Front Office, etc.)
*Primary Email (We do not give/sell your email address to anyone. This is how we communicate with you.)

 
 

 
Employment:
  • 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.
*Current Employer (Enter dentists name, not name of business)
*Address
*City    *State    *Zip
*Phone    Fax

 
 

 
Payment:
Yearly dues of $50 must accompany application.
 
*Name On Card:
*Card Number:
*Card Billing Address:
*Card Billing Zip Code:
*Expiration Date:
V-code/CVV2: (3 or 4 digit code printed on card)

 
 


Membership is annual and non-refundable



(Single click to avoid duplicate charges)