FADPA- Getting to Know You Form

The Florida Academy of Dental Practice Administration

Getting To Know You Form
It is the desire of The Florida Academy of Dental Practice Administration that you will find our meeting knowledgeable as well as enjoyable. By choice, the membership is limited in numbers with the belief that the limited membership encourages a stronger bond through the exchange of ideas and fellowship. So that we may know you better, please fill out this form.
Applicant Name*

First NameLast Name
Sponsoring Member Dentist Name*

First NameLast Name
Degree Title (Example: DDS, DMD, MS)*
DOB*
District*
Central (C), North Florida (NF), South Atlantic (SAC) or West Coast (WC)
Email*
example@example.com
Spouse/Partner Name

First NameLast Name
Spouse Email
Office Address*

Street Address

Street Address Line 2

CityDistrict

Postal / Zip Code
Home Address*

Street Address

Street Address Line 2

CityDistrict

Postal / Zip Code
What is your preferred mailing and directory listing address?*

OfficeHome
Cell Phone Number

Area CodePhone Number
Office Phone Number*

Area CodePhone Number
FDA Member Join Date
Dental School and Graduation Year
Years in Practice
Specialty*
Website
Expertise and Interests
Dental Organization Memberships and Offices Held
Meritorious Contributions to Dentistry
Advanced Dental Training
Expound on Special Interests in Dentistry
Clinics or Papers
What are some of the community activities in which you participate?
What are some of your hobbies, pastimes, and other activities you enjoy?
Anything else you would like to tell use so we could get to know you better?
FADPA P.O. Box 4482, Brandon, FL 33509

kelsey@fadpa.org * Ph: (813) 603-7503 * Fax: (813) 433-2433 * www.fadpa.org
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The Florida Academy of Dental Practice Administration

FADPA P.O. Box 4482, Brandon, FL 33509