IADT New Member Application


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Member Overview / Summary
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Contact Info Mailing Address needs to be updated:
Contact Name:
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Affiliation:
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Current Amount Due: $        
Make a Donation:
Contact information made available on the IADT Find a Dentist tab:
Member Classification
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Contact Information
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Last/Surname/Family Name: *
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Address 2:
Address 3:
Address 4:
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Email Address: *
Uncheck the following box if you do not want to be listed on the IADT Find a Dentist tab*  
Dental Traumatology Journal Information. Complete this address for DTJ delivery
Mail Address
Same as Contact Information?
Country:
Address 1:
Address 2:
Address 3:
Address 4:
City:
State/Province/Region:
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Journal Request History
to change your mailing address on an existing order below, click 'Edit Address' which will load the address above. Then click 'Save Updated DTJ Address'
Affiliation Information
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Department:
Position / Title:
Personal / Private Practice Website URL:
Member Photos

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Member Registration Payments
Membership Dues for 2019

                     

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Member Classification Change Request.
Fill out your comments below about why you wish to change. Click [Request Change] next to the Classification below that you wish to change to. The Membership Committee will review your request for consideration.
Comments:
 Classification
Membership with Online Journal (Annual Dues: $195 , Includes DTJ: Yes)
Membership includes online access to journal Dental Traumatology
Student (Annual Dues: $40 , Includes DTJ: No)
Does not include On-Line access to journal.
Student must be currently enrolled in a resident or student program and requesting to change membership to student status.


IADT - International Association of Dental Traumatology
IADT - International Association of Dental Traumatology



IADT - International Association of Dental Traumatology
APPLICATION FOR FOUNDATION FELLOWSHIP


Family / Last Name:
Title:
Given / First Name(s):
Name to appear on Fellowship certificate:   
Delivery method of Fellowship certificate:   

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Street address or PO Box:
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USD $250 Foundation Fellowship Fee
Total Amount: $
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Card Expires *
Name on Card * First: Last:
 




Phone: (858) 272-1018        Fax: (858) 272-7687        E-mail: membership@iadt-dentaltrauma.org        Website: www.iadt-dentaltrauma.org



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