Fill in the form fields below then PRINT, Sign and Mail to:

The Bronx Dental Society
3201 Grand Concourse - Suite 2N
Bronx, NY 10468



Fees do apply, Please call 718-733-2031, and ask for Joy.



Bronx County Dental Society Membership Application               ADA #

First Name:   MI:   Last Name:

Date of Birth:             Gender:   Male Female



Mailing Address:   Home Office


Home Address:
City:    State:     Zip:
Phone:         Fax:
Email:


Office Address:
City:    State:     Zip:
Phone:         Fax:
Email:

Is the practice a professional corporation?   Yes No
Do you also practice at other locations?   Yes No
Type:   General Practice      Practice limited limited to:
Board Certified?   Yes No
(Please submit documentation)



EDUCATION: College Degree Grad. Yr.
Dental
Postgraduate


Hospital, Internship, Residency and Military affiliation,
past and present(include dates started, completed and documentation):


NY State license#:        Date licensed#:

Are you currently registered with the NYS Dept. of Education   Yes No

Where you ever convicted of a felony or disciplined
by a state board for dentistry or state regents board:
   Yes No
(If Yes, explain):


Current or previous affiliations with dental associations (describe, note dates& ID/ADA #):


Were you ever rejected, deferred or suspended by a state or component society of the ADA?
Explain:


hereby state that I will conduct my practice in accordance with the accompanying Code of Ethics, which I have read. If at any time I should violate the Code of Ethics, it is understood that my membership may be forfeited in the Component Dental Society, The New York State Dental association and the American Dental Association.

If elected to membership, I agree to comply with all By-Laws, Code of Ethics, and the Rules and Regulations of the Component Dental Society, the New York State Dental Association, and the American Dental Association.

SIGN HERE