Become a Member

Join the Fifth District Dental Society

Join the Fifth District and automatically become a member of the New York State Dental Association and the American Dental Association. Founded in 1859, the ADA is the oldest and largest national dental society in the world. Membership in the tripartite allows you to take advantage of resources at all three levels of representation.


There are three ways to join:
1. Use the online form below -OR-
2. Download the application as a PDF here -OR-
3. Graduate Students and residents must use a different application available here


Membership Application

Home Address

Office Address


(Documentation of board certification is required. Please submit to your local dental society.)


Education

Dental

Postgraduate


By submitting this application, I hereby state that I will conduct my practice in accordance with the accompanying Code of Ethics, which I have read. If at any time I should violate the Code of Ethics, it is understood that my membership may be forfeited in the Component Dental Society, New York State Dental Association and the American Dental Association. If elected to membership, I agree to comply with all By-laws, Codes of Ethics, and other Rules and Regulations of the Component Dental Society, New York State Dental Association, and the American Dental Association. I attest that all the above information is true to the best of my knowledge.