New Member Application

New Membership Application

New membership dues are $195 and cover dinner at our monthly meetings, 12 hours of Continuing Education (CE), access to social events, and the chance to connect with local colleagues. The Upper Pinellas County Dental Association is affiliate of the with the American Dental Association (ADA), the Florida Dental Association (FDA), and the West Coast District Dental Association (WCDDA). To become a member, you must also join the ADA, FDA, and WCDDA within your first year and abide by the associations' Code of Conduct. The membership year is July 1 - June 30.
General Information
Full Name*

First NameLast NameNickname
FL Dental License Number*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone:*
Fax:
Email:*
Do you have a second office?*

YesNo
2nd Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone:
Website:
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Spouse's Name:
Academic Training
Dental School:*
Specialty
Degree:*
Year Graduated:*
Post Graduate:
Board Certification:
Year:
National and State Licenses
State Licenses (include year):*
Chronological History of Practice since Graduation:*
Practice:*

SoloAssociateLarge group practice
With whom:
Have you ever had your license suspended?*

YesNo
Please provide details:*
Have you ever been reprimanded for ethical misconduct?*

YesNo
Please provide details:*
Are you a member of other dental associations?*

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

CheckCard
Check Number:
Make checks payable to:

UPCDA

P.O. Box 611

Brandon, FL 33509

Please verify that you are human
I certify the above information is true.*

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New Membership Application

General Information

Academic Training

National and State Licenses