Waiver of Dues Application

*If you have retired, please complete the Retired/Retired Life Member Application.

Please complete this application with as much detail as possible that you would like to be taken into consideration of your dues reduction request. Email [email protected] with questions.

Waiver of Dues Application

Name(Required)

First Last

ADA Number

Local Society

Home Address(Required)

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

Email(Required)

Home/Cell Phone

I am requesting this waiver due to the following (select one):(Required)

Physical Disability (This option requires additional information beyond this form that the MDA will provide to you.)

Service to Country

Financial Hardship

Limited Hours/Income

Please answer the following questions:

1. Are you able to practice dentistry?(Required)

Yes

2. What is the number of patients seen per week?(Required)

3. What are the number of hours practicing dentistry per week/month?(Required)

4. Are you earning an income from the practice of dentistry, the faculty of a dental school, or as a consultant?(Required)

Yes

(If you do not earn an income, please complete the Retired/Retired Life Member Application. Please note that you can volunteer in the field of dentistry and be considered a retired member.)

Please use the space below to describe your current employment situation that you would like the MDA to take into consideration.(Required)

Signature(Required)

First Last

Date(Required)