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 an affiliate of 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:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Email:
Do you have a second office?
2nd Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone:
Format: (000) 000-0000.
Website:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Spouse's Name:
Academic Training
Dental School:
Specialty
Degree:
Ex: DMD, DDS
Year Graduated:
Post Graduate:
Board Certification:
Year:
National and State Licenses
State Licenses (include year):
Chronological History of Practice since Graduation:
Practice:
With whom:
Have you ever had your license suspended?
Please provide details:
Have you ever been reprimanded for ethical misconduct?
Please provide details:
Are you a member of other dental associations?
Please provide a list of the other associations you are a member of:
Please upload a headshot for our website:

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Payment Method:
Check Number:
Make checks payable to:

UPCDA

P.O. Box 611

Brandon, FL 33509

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New Membership Application

General Information

Academic Training

National and State Licenses

*