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2002 ADAA NEW ACTIVE MEMBER
APPLICATION
Send payment to:��������� American
Dental Assistants Association, P.O. Box
803182, Chicago, IL 60680-3182
ADAA Member Previously? (If YES, When):______Social
Security#___________________ Date: ___________
Name:___________________________________________________________________________________
(FIRST)��������������������������������������������������������� (MIDDLE)����� ����������������������������������������������������������������������� (LAST)
Address:__________________________________________________________________________________
(STREET)����������������������������������������������������������������������������������������������������������������������������������������������������� ����������������������� (APT #)
_________________________________________________________________________________________
(CITY)����������������������������������������������������������������������������������� (STATE)�������������������������������� ����������������������������������������������� (ZIP)
Home Phone:
(_____)_____________________Business Phone: (_____)__________________________
State Dental Assistants
Association: ____________________��������������� Local
Dental Assistants Organization: _____________________
Sponsor (If
any):___________________________________________
Please specify: CDA Number: ___________________RDA
Number: ____________________
How Did You Learn About
ADAA?________________________________________________________
Please check applicable area:
Chair side: __________
Business Assistant: __________ Office Manager: __________ Educator: __________
Other:____________________________________________________________________
By joining the ADAA, you also become a member of a state
and local organization, if one exists.�
Local membership will be in the same state as state membership.� State/Local dues amounts are listed.� This amount must be added to your ADAA dues.
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MEMBERSHIP
FEES: If
you want to pay in full: |
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If
you want to pay in two installments: |
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ADAA
New Active Dues |
$105.00 |
One-half
of ADAA New Active Dues |
$52.50 |
|
Professional
Liability Insurance (not
optional) |
$10.00 |
Professional
Liability Insurance (not
optional, this Insurance is paid IN FULL in the first installment and does
not appear in the second installment invoice) |
$10 |
|
State/Local
Dues (enter
amount from State List) |
$ |
One-half
of State/Local Dues (1/2
of amount from list) |
$ |
|
TOTAL
DUES (if paid in full) |
$ |
Semi-annual
fee (semi-annual fee does not appear in the second invoice) |
$5.00 |
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Payment
Made By: Circle One Mastercard��� Visa���
Check |
|
Total
Dues (if paid in installments) |
$ |
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Total
Payment Enclosed: |
$ |
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Account# _________________________ Exp. Date.______ Cardholder
Signature: _______________________
Cardholder
Name: ______________________________
Cardholder Address:
_________________________________________________________________________
If
different from above
MAKE
CHECKS PAYABLE TO ADAA
o
No portion of ADAA fees are
refundable or transferable, note: $0.48 cents of your ADAA dues are not tax
deductible.
o
Membership includes a
subscription to The Dental Assistant, $1,000,000 aggregate
professional liability insurance, $1,000 accidental death & dismemberment
insurance
o
Membership and professional
liability insurance become effective following receipt and processing of
application, AD&D insurance becomes effective upon return of a beneficiary
card, which will be sent to you with your ADAA membership card