Pasco Membership Application

Chronological History of Practices Since Graduation and Past Information
Please list practice, year(s) worked, and if the practice was solo, associate, or other.
If an associate, with whom?
Have you ever had a patent complaint to any professional relations committee? If yes, please explain:*
Have you ever been investigated by the department of professional regulation? If yes, please explain:*
Have you ever been convicted of a felony? If yes, please explain:*
Have you ever been convicted for drug abuse? If yes, please explain:*
Have you ever had your license suspended? If yes, please explain:*
Have you ever been reprimanded for ethical misconduct? If yes, please explain:*
Have you ever belonged to another dental association either in or out of state? If yes, list names, places, and dates.
I certify the above information to be true. I authorize the Pasco Membership Committee to seek information, if needed, concerning the above questions. I understand that the Pasco County Dental Association is an affiliate organization of the American Dental Association, Florida Dental Association and the West Coast District Dental Association (“tripartite”). I understand that my membership in the Pasco County Dental Association is contingent upon my membership in good standing of this tripartite. I certify that I will abide by the articles of incorporation and bylaws and code of ethics of the Pasco County Dental Association.*

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