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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

If you are a human and are seeing this field, please leave it blank.

Membership Application

ADA #

Last Name

First Name

Middle Initial

Date of Birth

Male
Female

Home Address

Address H

City

State

Zip Code

Phone

Fax

Email

Office Address

Address O

City

State

Zip Code

Phone

Fax

Email

Preferred Mailing Address:

Home
Office

Is the practice a professional corporation?

Yes
No

Do you also practice at other locations?

Yes
No

Practice Type

General Practice
Other

If Other Practice Limited to:

Board Certified?

Yes
No

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

Education

Dental

College

Degree

Grad. Year

Postgraduate

Postgraduate College

Postgraduate Degree

Postgraduate Grad. Year

Please list and describe Hospital, Internship, Residency and Military affiliations, past and present (include dates started, completed and documentation).

NY State License #

Date Licensed

Are you currently registered with the NYS Dept. of Education?

Yes
No

Current or previous affiliations with dental associations (describe, note dates and ID/ADA #)

Were you ever convicted of a felony or misdemeanor or disciplined by a state board for dentistry, state regents board, other governmental agency, or other dental or professional organization?

Yes
No

(if yes, please explain in the field below)

Are you currently under investigation by any licensing body, governmental agency, or dental or other professional organization, which could lead to disciplinary action?

Yes
No

(if yes, please explain in the field below)

Were you ever disciplined or had an application for membership rejected, deferred or suspended by a state or component society of the ADA, or other dental or professional organization?

Yes
No

(if yes, please explain in the field below)

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.

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