Tripartite Membership Application
For membership in the American Dental Association, Illinois State Dental Society and your local dental society.

Thank you for your interest in becoming a member of organized dentistry. The American Dental Association, Illinois State Dental Society and your local dental society have a tripartite membership structure. Therefore, final approval of your application provides you with membership at all three levels of your professional associations: local, state and national. Your application will be processed by ISDS and your local society. ISDS may request additional information and will provide you with complete information regarding membership dues as well as the Bylaws and the Principles of Ethics and Code of Professional Conduct of the ADA and ISDS, which govern the professional conduct of members.

Fields in RED are required


(if known)
Maiden Name: Birthday: (mm/dd/yyyy)
Male
Female
Mail Delivery Preference:
Is Spouse Dentist:

Office Information

Address: City, State, Zip:
   

Personal Information

City, State, ZIP:
   

Professional Information

   
Degree:

Other
Dental School:
Graduation Date: (mm/dd/yyyy)

Advanced Education Program

City, State:
Certificate / Degree:

 

Program Area(s): Endo
Pediatric
Perio
Public Health
Prostho
Ortho
Oral Path
Oral Surg
Gen Practice
Other

Is your practice limited to this specialty?:
Yes No
       
Currently Practicing?: Yes
No
Looking for practice
opportunity in:
Practice Description: Solo
Group
Partnership
Associateship
Clinic
Faculty
Federal Dental Service
Other
   
If practicing in other than a solo practice, please indicate the group of practitioner's name and location:
Name: Address:
Licensed?:

Presently  (State License Number: )
License Pending 
No Illinois License

 

Dental Association Membership Status

Are / were you a member of the American Student Dental Association:
Yes
No
If Yes, from to
 
Please indicate your membership status in the American Dental Association:
Current member in with dues paid for the membership year.
Was previously a member in and from to
 



Endorsed Products & Services

From office products to financial
services, insurance
to logo items,
shop the ISDS
Store for all your
business needs.

Shop the ISDS store for your business needs
Deco