PCDA Membership Application

As a member, you have access to monthly meetings, dinner, and special events. In-person meeting information and details can be found online here.

Your application will be reviewed and voted upon by the PCDA Board and you will be recognized as a New Member in the e-newsletter and first meeting you attend.

The annual membership dues cycle runs each year July 1 - June 30.

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Degree*

DMDDDS

Office Website

Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Office Phone Number*

Please enter a valid phone number.

Office Fax Number

Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home/Cell Phone Number*

Please enter a valid phone number.

Preferred Mailing*

OfficeHome

Spouse Name

Is your spouse a dentist?

YesNoN/A

Florida License Number

License in Other State(s)

Dental School*

Date of Completion*

Specialty

Date of Completion

Board Certified

YesNo

Previous Membership in Other Local Dental Associations:

Please tell us how you heard about the Pinellas County Dental Assocation and why you chose to join.*

The privilege of membership in the Pinellas Dental Association entails the responsibility of participation in the activities of The Association.

Payment Type

CardCheck

Check Number

Check Amount (See Prices Below)

Make checks payable to the PCDA:

Pinellas County Dental Association

P.O. Box 1833

Brandon, FL 33509

Payment

Active Member

$350.00

Public Health Employee

$300.00

1st Year New Dentist

$175.00

Life Member

$175.00

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

I hereby make application for membership in the Pinellas County Dental Association and agree to abide by the By-Laws of the organization.

I understand that my membership in the Pinellas County Dental Association will be provisional for a period of one year, upon acceptance and that active status is dependent upon membership in the West Coast District Dental Association, The Florida Dental Association and the American Dental Association during this one year period.

Your personal contact information will not be shared with anyone outside of the organization.

Your name, office address, office phone and office website will be placed online at www.smilepinellas.org in the Find-a-Dentist section.

Signature*

Clear