MDS OLD - Membership Renewal

Please use this form to renew your membership and to provide the information we will use in the Find a Dentist directory on our new website. You can also upload an image of you, your practice, and your logo. In the payment section you can choose to pay online. If you have already renewed or you are mailing a check please fill out the informaion and select Already Renewed or Mailing Check.

Your cell phone, preferred address, email, and school will not be publised on the public directory.

Please provide as much information as possible. Fields with an * are required.

Renewals are due by April 10th, 2024.

Full Name*

First NameMiddle InitialLast Name

Dental School Attended*

Year Graduated

DDS/DMD*

Speciality

General, pediatric, Ortho, etc.

Practice Name

Office Phone

Cell Phone

E-mail*

Business Website

Office Address (physical address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

County

Preferred Address (if different from above office address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Send an image to use on our new Find a Dentist Directory

Include an image of you, your practice, or your logo, or all of these.

MEMBERSHIP DUES*

Past Due Membership duesAfter March 1st, 2025

$550.00

RetiredPlease see the policy on membership below, no longer practicing dentistry.

$210.00

ResidentGraduates in the past 12 months

$5.00

Already RenewedSubmitting information only

$ Free

Mailing CheckInformation provided via form - please mail check

$ Free

Total

$0.00

Credit Card

To pay by check, please print the completed form and mail to
MS Dental Society - P O Box 55613, Jackson MS, 39110
Payment made by check; Dues- $500, Past Due- $550

Retired Member Any active member in good standing who has been an active member for twenty-five (25) years or more, having attained the age of sixty-two (62) and no longer earning income from the performance or service as a member of the faculty of a dental school, as a dental administrator or consultant, or as a practitioner of any activity for which a license to practice dentistry or dental hygiene is required by the state, may be classified as a retired member upon application to the Board of Trustees not later than June 30 in any year. A retired member shall be entitled to all privileges of an active member except that his years of Retired membership shall not be included as years of active membership for the purpose of determining eligibility for life membership.