FAP Membership Application

Membership Application
Date

MonthDayYear
Date
Name:*

First NameLast Name
Degree Title(s):*
Email:*
example@example.com
Cell Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Office Number:
Please enter a valid phone number.Format: (000) 000-0000.
OfficeHome
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
YesNo
Website URL:
Dental License Number: *
ADA Member #:
AAP Member #:
Graduation Year and Dental School:
Periodontal Training and Year:
List any other dental organizations you belong to:
*To be a member of the FAP, you must meet the requirements of the American Dental Associaiton and the State of Florida for the specialty of Periodontics and must be in good standing with the Board of Dentistry.
Annual Membership Dues: $350

Application Fee: $50

Mail checks paybale to the:

Florida Association of Periodontists

P.O. Box 4482

Brandon, FL 33509

Recent graduates of a periodontics program (within 1 year) are eligible for membership. The first year includes no application fee or dues.
CardCheck
Check Number:

My Products

Application Fee

$50.00

Active Member Dues

$350.00

Total

$0.00

Submit Copy of Certificate in Periodontics

Cancelof
I hereby apply for membership in the Florida Association of Periodontists and certify that my practice is limited to Periodontics. *

Clear
Should be Empty: