FACD Membership & Renewal

Name:*

PrefixFirst NameLast Name

Designation (Example: DMD, DDS):*

If not applicable, please put N/A

Email:*

example@example.com

Are you a renewing your membership or a new member?*

Please select your membership type:*

Office/School Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Accredited University or College:*

Office Phone Number:*

Please enter a valid phone number.

Practice Name*

Practice Website*

Home Address (For mailing purposes)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Preferred Mailing Address*

OfficeHome

Payment Type:*

CardCheck (If you would like an invoice please email us at facd.info@gmail.com)

Please make checks payable to:

Florida Academy of Cosmetic Dentistry | PO Box 4373 | Brandon, FL | 33509

Check Amount:

Check Number:

Card Payment:*

Membership Dues (Doctor/Lab Technician)

$500.00

Membership Dues (Full Time Faculty)Teaching staff of an accredited university or college, full-time.

$200.00

Membership Dues (Recent/Post Graduate) 1-2 years out of school

$100.00

Membership Dues (Student)Current student of an accredited university of school.

$50.00

Speaker Fund DonationThis is to support speakers for FACD related events.

$100.00 Quantity

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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