New Active Dental Tech Membership

Personal Info:

 DDS   DMD   CDT  

Date of Birth

Specialty Certified (Choose all that apply)
 Crown & Bridge  
 Complete Dentures  
 Removable Dentures  

Date Certified

Current Employment (Chose all that apply)
 Owner/Manager- Commercial Dental Laboratory  
 Employed Technician- Commercial Dental Laboratory  
 Technician- Private Dental Office  
 Dental Technology Educator  
 Government Technician  

Mailing address:

Privacy Information

Do you consent to receive email communications from us, regarding your membership?
 Y    N

Show in member directories?
 visible    hidden

Who can view member details?
 public    members only    administrators only

Nomination by APS Member

(If applicant is not closely related with a member, Central Office will be of assistance.)

If an APS Member is not known, please indicate how you heard about APS (internet, colleague, email, etc.)

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