Student Membership Application

Education

After graduation, I plan to begin the following

Program State

School (GPR, Postgrad)

Postgrad Completion Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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I plan to practice in

Practice State

Personal Information

First Name *This question is required.

Middle Name

Last Name *This question is required.

Suffix

ADA #

Street Address *This question is required.

Address 2

City *This question is required.

US State *This question is required.

Zip *This question is required.

Gender *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Phone *This question is required.

Cell *This question is required.

Receive Texts *This question is required.

Personal Email *This question is required. This question requires a valid email address.

School Email This question requires a valid email address.

Membership Acknowledgements and Agreements

A. Bylaws and Compliance Agreement

I hereby agree to abide by the CDA Code of Ethics, the ADA Principles of Ethics and Code of Professional Conduct and the bylaws of the component dental society, the California Dental Association and American Dental Association.

B. Membership Agreement

I CERTIFY THAT all statements made by me in this application are complete, true and correct. I agree that if any such statements are found to be false, or if there are material omissions made, this application may be rejected solely on those grounds, or in the event such false statement or omission does not become known to the dental society until after I have been elected, that I may be removed immediately from membership on the basis of the false statement of omission alone. For the purposes of this paragraph, I understand that a material misstatement or omission shall mean one which is “not insubstantial” or one which is “significant in relation to the questions asked.“ Upon becoming a member, I hereby waive the right to hold component dental society, CDA, ADA, or any member thereof, responsible for any damage in case of disciplinary action involving me, after a hearing in accordance with the bylaws of these organizations.

C. Phone, Fax and Email Consent

I understand that by providing the phone and fax number(s) and email address(es) in this application, I hereby consent, on behalf of myself and on behalf of any entity specified in this application, to receive phone calls, faxes and emails sent by or on behalf of the component dental society, California Dental Association, American Dental Association, The Dentists Insurance Company, TDIC Insurance Solutions, and California Dental Association Foundation. If I am giving this consent on behalf of an entity specified in this application, I hereby represent and warrant that I am duly authorized to execute and deliver this consent on behalf of that entity.

Electronic Signature

By checking the electronic signature checkbox below and typing in my first and last name in the space provided, I (i) acknowledge that I have read and agree to the foregoing terms and conditions of this application, (ii) certify that all statements made in this application are complete and accurate, and (iii) that I am signing this application using my electronic signature.

*This question is required.

Electronic signature (type full name) *This question is required.

By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.