2024-25 Membership Application

HCDA New Membership Application Protocol
Application Process

An application can be completed. A dues payment of $245 for a full year is required. The application, dues and administrative fee must be received at least one month before the next HCDA meeting so the applicant's name can be posted in the HCDA Newsletter per HCDA Bylaws. If applying after the January meeting dues will be prorated for ½ year of membership to $147.50. Applicants must also be a member in good standing with the Florida Dental Association (FDA) and the West Coast District Dental Association (WCDDA). If Not a member of the FDA or WCDDA at time of application, you must join these associations within one year of application date. Active duty military and government employees are Not required to join the FDA and WCDDA.
Membership Status

New members will be notified of the upcoming meetings and events, and will be able to attend the remaining HCDA functions for the membership year.
Membership Year/Dues

The HCDA membership year runs from August through May. Membership dues include four general membership meetings, continuing education and dinner at these meetings, and then attendance at the kickoff party for member and a guest. Members are kept abreast of the latest developments affecting dentistry through five HCDA newsletters and through the website. The HCDA central office is available to answer your questions and/or direct you to the proper resources.
Membership Application
Full Name*

First NameLast Name
Nickname
For name badges
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Office Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell/Home Phone Number*

Area CodePhone Number
Please send mail to:*

Business AddressHome Address
Academic Training
Dental School:*
Degree:*
Year Graduated:*
Post Graduate:*
Board Certification:*
National and State Licenses
State Licenses (include year):*
National Licenses or Boards (include year):*
Practice Type:*

SoloAssociate
If associate, with whom
Have you ever had patient complaints to any professional relations or peer review committee?*

YesNo
If answered yes to the previous question, please provide details.
Have you ever been investigated by the Department of Health of the Board of Dentistry?*

YesNo
If answered yes to the previous question, please provide details.
Have you ever been convicted of a felony?*

YesNo
If answered yes to the previous question, please provide details.
Have you ever been arrested for drug abuse?*

YesNo
If answered yes to the previous question, please provide details.
Have you ever had an action taken against your license?*

YesNo
If answered yes to the previous question, please provide details.
Have you ever been reprimanded for ethical misconduct?*

YesNo
If answered yes to the previous question, please provide details.
In order to be and HCDA member, you have to be an active tripartite member (ADA, FDA, WCDDA member). Please confirm below:*

Yes, I am and active tripartite member.No, I am not a tripartite member.
Have you ever belonged to another dental association either in or out of state?*

YesNo
If yes, please give names, places, and dates:
I certify the above information to be true.*

Clear
I certify that I will abide by the constitution and bylaws and the code of ethics of the Hillsborough County Dental Association.*

Clear
I authorize the Hillsborough County Dental Association Membership Committee to seek information concerning the above questions for use in considering my candidacy for membership in the above said organization.*

Clear
I certify that I am an ethical practitioner of dentistry and hereby apply for active membership of the Hillsborough County Dental Association. I authorize the release of any information to the Membership Committee of the Hillsborough County Dental Association for its use in considering this application.*

Clear
Be prepared to appear before the Hillsborough County Dental Association Executive Council to present your Dental School Diploma, State License and Board Specialty.*

Clear
Payment Information
Payment Type

CardCheck
Check Number
Make checks payable to:

HCDA

P.O. Box 202

Brandon, FL 33509

Payment (*Make sure to check box):

Annual Membership Dues$245.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human
Should be Empty:

HCDA New Membership Application Protocol

Application Process

Membership Status

Membership Year/Dues

Membership Application

Academic Training

National and State Licenses

Payment Information