INTEGRITY ~ COMPASSION ~ RESEARCH ~ EDUCATION ~ FELLOWSHIP

 

(PLEASE PRINT)

NAME (as you would like it to appear on membership, certificates, website etc.)

 

First Name                                                         Initial                  Last Name                                                                        State Dental License Number                          

                                                                                                                                                                                                                                               

 

ADDRESS

 

Practice Name                                                                                                                                                                                                                    

 

Office Address                                                                                      City                                                             State               Zip                            

 

Telephone                                                                                         Fax                                                                                                                    

 

Email                                                                                                      Web Address                                                                                                      

   

Personal Email                                                               

 

                                                                                                                                                                                                                                               

 

EDUCATION

 

Dental School                                                                Degrees                                    Date rec’s                               

 

Graduate School                                                           Degrees                                    Date rec’s                               

 

Specialty                                                                       

 

                                                                                                                                                                                                                                               

 

EXPERIENCE IN IMPLANT DENTISTRY

 

Implant continuing education hours in last 3 years                      

 

Experience in implant dentistry:   □ Less than 25 cases    □ 25 – 100 cases    □ more than 100 cases

 

Involvement with implant dentistry:    □ Surgery    □ Prosthetics   □ Periodontics/Maintenance   □ Academic

 

Continue on reverse….
INTEGRITY ~ COMPASSION ~ RESEARCH ~ EDUCATION ~ FELLOWSHIP

Membership Application – Continued

                                                                                                                                                                                                                                               

 

ANNUAL U.S. MEMBERSHIP DUES INCLUDE:

 

■   Subscription to website and on-line magazine

■   International certification program: General Membership, Fellowship, Mastership credentialing

■   IAMDI website listing and link to your practice at www.iaomdi.org

■   Discount on patient education materials

■   Special member discounts to IAMDI solely sponsored meetings

■   Certificates of membership

                                                                                                                                                                                                                               

 

MEMBERSHIP CATEGORY SELECTION

 

(Please check the appropriate category)

□  CATEGORY I         Dental Practitioner – Initial Registration Term Expires 4-1-2011………...........................................  $700.00

□  CATEGORY I         Dental Practitioner – Annual Renewal….………… ……………........................................... .     $400.00             

□  CATEGORY II         Full-Time University Faculty/Military – Initial Registration Term Expires 4-1-2011………………… $500.00

□  CATEGORY II         Full-Time University Faculty/Military – Annual Renewal……...……………………………………..... $300.00

□  CATEGORY III       Pre-doctoral or Graduate Dental Student……...………………………………………………………... $100.00

                                                                                                                                                                                                               

 

PAYMENT INFORMATION

 

Checks – Please make checks payable to IAMDI in US funds and mail to the address below

 

Credit Cards - Please complete the following information and fax both sides of this form to +1.817.560.8947

 

                                    □  Master Card               □  Visa                 □  American Express            □  Discover

 

Card Number                                                                                                        Exp Date               CCSC Code (3 digit code)                               

 

Signature                                                                                                                                               Date                                                                     

 

                                                                                                                                                                                                               

 

 

RETURN THIS APPLICATION WITH YOUR MEMBERSHIP DUES TO THE IAMDI CENTRAL OFFICE:

 

8020 Camp Bowie West ~ Fort Worth ~ TX ~ 76116

 

PH.+1.817.560.0414      FAX +1.817.560.8947