Dual Membership Application

2024 DUAL MEMBERSHIP APPLICATION
Qualifications: This category of membership is a for a member dentist in good standing with the American Dental Association, who is not eligible for voting membership in the Florida Dental Association.

This membership is for the Florida Dental Association only and does not include Florida component societies.

Sampling of Benefits: Professional Support • Florida Dental Convention (free pre-registration) and member rate for courses • FDA website “Member Only” access • Today’s FDA Publication • Free Online CE • Access to FDA Crown Savings Program for discounts on products and services.
- Dues: 25% of FDA full dues per calendar year 2024 - $130.00
Full Name

First NameLast Name
Preferred Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number (If applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth:

MonthDayYear
Date
I am a member of the:
State Dental Society/Association
Florida License Number (if applicable):
ADA Number
I certify that I am a member in good standing with the ADA and wish to apply for Dual membership in the Florida Dental Association.
Signature
Date

MonthDayYear
Thank you for completing your FDA dual membership application. You will be receiving a Docusign via email from Bettie Swilley or Megan Bakan to submit your $130 dues payment securely. Welcome to the FDA family!

Florida Dental Association, 545 John Knox Rd, Ste 200 • Tallahassee, FL 32303

Questions: Call our Member Relations Department at 1-800-877-9922.
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2024 DUAL MEMBERSHIP APPLICATION