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Tripartite Membership Application

For membership in the American Dental Association, Michigan Dental Association and your local dental society.

Please complete all sections of this application.

Thank you for your interest in becoming a member of organized dentistry. Your application will be processed and considered by the Michigan Dental Association and your local dental society, which will provide you with additional information regarding specific application procedures. For complete information regarding the Bylaws and the Principles of Ethics and Code of Professional Conduct of the ADA, which govern the professional conduct of members, please visit the ADA Web site.

Personal

Primary Office Address

Home Address

Spouse Name
First
Last
Middle



Some societies offer assistance in locating a practice situation. Contact your local dental society for information regarding their services.




Have you ever been convicted of a felony or criminal offense, including driving under the influence of alcohol or drugs, but excluding minor traffic violatios and parking tickets? (A conviction record will not automatically bar you from membership. Each application will be individually considered on its merits.) *

I hereby apply for tripartite membership in the American Dental Association and resolve to abide by the Bylaws and Principles of Ethics and Code of Professional Conduct if accepted into membership. *

* Required

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