Retired/Retired Life Membership Application

Retired/Retired Life Membership is available to an active member in good standing who is no longer earning an income from the performance of service as a member of the faculty of a dental school, as a dental administrator or consultant, or as a practitioner of any activity for which a license to practice dentistry is required by the state. Members must retire on or before March 31 of the current dues year to qualify for a dues discount.

Email [email protected] with questions.

Retired/Retired Life Membership Application

Name(Required)

First Last

ADA Number

Retirement Date(Required)

Date of Birth

Permanent Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Home/Cell Phone

Signature(Required)

First Last

Date(Required)