New Member Application

Full Name *

First Name Last Name Nickname

Office Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Office Phone: *

Fax:

Email: *

Do you have a second office? *

Yes No

2nd Office Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Office Phone:

Website:

Home Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Phone:

Spouse's Name:

Dental School: *

Specialty

Degree: *

Year Graduated: *

Post Graduate:

Board Certification:

Year:

State Licenses (include year): *

Chronological History of Practice since Graduation: *

Practice: *

Solo Associate Large group practice

With whom:

Have you ever had your license suspended? *

Yes No

Please provide details: *

Have you ever been reprimanded for ethical misconduct? *

Yes No

Please provide details: *

Are you a member of other dental associations? *

Yes No

Please provide a list of the other associations you are a member of: *

Payment Method:

Check Card

Check Number:

Make checks payable to:

UPCDA

P.O. Box 611

Brandon, FL 33509

*

New Member Application Fee

$ 195.00

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 certify the above information is true. *

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Membership Application

General Information

Academic Training

National and State Licenses