Regular Members
Registration Fee:             $   15.00
Annual National Dues:    $ 334.00
State Dues:                     $   34.00
TOTAL                            $ 383.00

1st Year Graduate:    $  67.00
2nd Year Graduate:   $134.00
3rd Year Graduate:    $200.00
4th Year Graduate:    $267.00

Return application and remittance to:

Academy of General Dentistry
211 East Chicago Avenue
Chicago, IL  60611

Name: _____________________________________________________________________

Date of Birth: _______________________ ADA No. (If available): ______________________

Business Adress: ____________________________________________________________

City: ___________________________ State: __________________ Zip: ________________

Residence Adress: ___________________________________________________________

City: ___________________________ State: __________________ Zip: ________________

Business Phone: (          ) __________________ Home Phone: (          ) ___________________        

DENTAL SCHOOLS ATTENDED

Name: ____________________________________________________________________

From: ___________________ To: _________________ Degree: ______________________

Name: ____________________________________________________________________

From: ___________________ To: _________________ Degree: ______________________

Are you a general dentist?             YES     NO

Do you limit your practice?            YES    NO

If so, what specialty? ________________________________________________________

Are you in private practice?           YES   NO

If not, explain (Armed  Forces, Public Health, Education, etc.): ________________________

_________________________________________________________________________

Are you a member of a state dental association?     YES     NO

If so, which association: _____________________________________________________

Date: _____________________ 

Signature: ________________________________________________________________

@2004