New Student Dental Technologist Member Membership

Personal Info:





Designation
 DDS   DMD   CDT  


Date of Birth








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

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  
 Other  

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

Education Details:












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.)



Program Director

Please list name, complete address (email if available) of Program Director from whom a letter of recommendation will be sent:

Name of Program Director (Letter of Recommendation must be sent from Program Director to for acceptance to APS)







Date










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