MDS Membership Application

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

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

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

Affiliate Membership requires you to be a member, in good standing, of the American, Florida and West Coast District Dental Associations.

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Degree*

DMDDDS

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

Initial Date of Practice in Manatee County*

Practice Type*

SoloAssociateContract

Undergraduate School*

Date of Completion*

Dental School*

Date of Completion*

Specialty

Date of Completion

Spouse Name

Is your spouse a dentist?

YesNoN/A

Date of FL Board

Florida License Number*

License in Other State(s)

Postgraduate Training:*

Chronological History of Practice Since Graduation.*

Have you ever belonged to another Dental Assocation either in or out of state? If yes, please give names, place and dates:

Have you ever been investigated by the Board of Dentistry?*

YesNo

If yes, give details:

Have you ever been investigated by the Department of Regulation?*

YesNo

If yes, give details:

Have you ever been convicted of a felony?*

YesNo

If yes, give details:

Have you ever been convicted for drug abuse?*

YesNo

If yes, give details:

Have you ever had your license suspended?*

YesNo

If yes, give details:

Have you ever been reprimanded for ethical misconduct?*

YesNo

If yes, give details:

I certify the above information to be true.

I certify that I will abide by the Articles of Incorporation and the By-laws of the Manatee Dental Society. I authorize the Membership Committee to seek information concerning the above questions or use in considering my candidacy for membership into the Manatee Dental Society.

I certify that I am an ethical practitioner of dentistry and hereby apply for membership in the Manatee Dental Society.

Signature*

Payment Type

CardCheck

Check Number

Check Amount (See Prices Below)

Make checks payable to the MDS:

Manatee Dental Society

P.O. Box 1833

Brandon, FL 33509

Payment

New Member

$375.00

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

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