I am applying for APS Membership as (all first-year membership fees include mandatory online subscription to The Journal of Prosthetic Dentistry except Graduate Student):
Active Practicing Dentist (USA)
$435.00
Active Practicing Dentist (International including Canada)
$435.00
Active Dental Technologist (USA)
$276.00
Active Dental Technologist (International including Canada)
$276.00
Graduate Student (Current)
No Fee
Active Recent Graduate (within 5 years)
3 Year Graduated Reduced Dues Schedule-1st year
$215.00
Information
Credentials:
(DDS, DMD, CDT, etc.)
First Name:
Middle Initial:
Last Name:
Address:
City/State/Zip:
/
/
Country:
Phone:
Work:
Cell:
Home:
Fax:
Date of Birth:
Email:
Gender:
Male:
Female:
Active Practicing Dentist Membership Applicants Only
Dental Degree From:
Year:
Other Degrees From:
Degree / Year
Certificates or additional specialty training (please specify):
Type of Practice:
General
Prosthodontics
Military
Hospital
Education
Other:
ADA Member?:
Yes
ADA#
Are you a member of another national Dental Association?:
Yes
Name of Other Association:
No
Board Certified:
Yes
No
Board Eligible
Yes
No
active dental technician membership applicants only
Training/School:
CDT#:
Year of Graduation:
Specialty(ies) Certification:
Fixed Prosthetics
Complete Dentures
Removeable Partial Dentures
Ceramics
Current Employment:
Owner/Manager, Dental Laboratory
Technologist, Dental Laboratory
Technologist, Private Dental Office
Dental Technology Educator
Government Technologist
Other
For Active Applicants Only
Nomination by APS Member (If applicant is not closely related with a member, Central Office will be of assistance.)
Name of Member:
Phone:
Contact Email:
Date:
Graduate Student Applicants Only
Dental Degree(school):
Year:
Month/Year of (scheduled) completion of Graduate Program:
Type of Program:
General
Prosthodontics
Implants
Periodontics
Other
Please list name, complete address (email if available) of Program Director from whom a letter of recommendation will be sent:
Name-Program Director:
School:
Address:
City/State/Zip:
/
/
Contact Email:
If Elected to Membership in the American Prosthodontic Society, I agree to abide by the Bylaws of the Society
