FPA Membership Application

Select Membership Category:

ActiveAssociateAffiliateLife

Name:

First NameLast Name

Degree Title(s):

Email:

example@example.com

Cell Phone Number:

Please enter a valid phone number.

You have my permission to include my email in the membership directory:

YesNo

Office Name:

Office Phone Number:

Please enter a valid phone number.

Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Mailing Address:

OfficeHome

If Applicable, Spouse's Name:

Dental Degree and Year Graduated:

Other Degrees and Year(s):

Advanced Formal Training and Year(s):

Are you board certified?

YesNo

Are you licensed to practice in Florida?

YesNo

Dental License Number

Are you licensed in any other states?

What year did you become a member of the American Board of Prosthodontics?

Presently, if you are part of a dental department in the Army, Navy, Air Force or Veterans Administration, give rank and date of beginning service:

Are you a member of the ADA?

YesNo

*ADA membership is not a requirement for FPA Membership. However, all members are encouraged to become member of the American Dental Association.

List any other dental organizations you belong to:

Payment:

CardCheck

Check Number:

Annual Membership Dues: $545

Mail checks paybale to the:

Florida Prosthodontic Association

P.O. Box 4373

Brandon, FL 33509

Signature

Please check the below box if paying by card:

Active Member Dues

$545.00

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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