Tripartite Application

1 Personal

2 Education

3 Work

4 Membership Dues

Confirm your personal details

Your Name

First Name*

Please provide a valid value.

Last Name*

Please provide a valid value.

Current Home Address

Street/Unit Number*

Please provide a valid value.

Street Address*

Please provide a valid value.

City*

Please provide a valid value.

State/Province*

Please select an option.

ZIP Code*

Please provide a valid value.

Country*

Please select an option.

Personal Phone Number *

Please provide a valid phone number.

1 Personal

2 Education

3 Work

4 Membership Dues

Tell us about your education and residency

Dental School

I went to dental school in the U.S.

I went to dental school outside of the U.S.

Please select an option.

State/Province*

Please select an option.

Dental School Name*

Please provide a valid value.

Graduation Date

Please provide a valid date.

Country*

Please select an option.

State/Province*

Please select an option.

Dental School Name*

Please provide a valid value.

Graduation Date

Please provide a valid date.

Select a Specialty

Please select an option.

Residency

I completed my residency

I'm completing an ongoing one

I did not do a residency

Please select an option.

State*

Please select an option.

Start Date*

Please provide a valid date.

End Date

Please provide a valid date.

What is your specialty?

Please select an option.

1 Personal

2 Education

3 Work

4 Membership Dues

Provide your dental license and work details

Dental License

License Type

Please select an option.

State

Please select an option.

License Number

Please provide a valid value.

Issue Date

Please provide a valid date.

Expiry Date

Please provide a valid date.

What is your current position?

I'm currently working, with my own practice

I'm currently working as an employee, associate, or work in corporate

Please select an option.

I will be a full-time faculty member at a dental school

I'm not working currently

I'm retired

Please select an option.

Work Address

Street/Unit Number

Please provide a valid value.

Street Address

Please provide a valid value.

City

Please provide a valid value.

State/Province

Please select an option.

ZIP Code

Please provide a valid value.

Country

Please select an option.

Add your practice to ADA Find-a-Dentist^® directory? (Optional)

ADA Find-a-Dentist^® helps millions of people nationwide locate dental care providers in their area. Add your practice to our directory and connect with new patients-at no cost as part of your membership. Learn More

Yes include my work address

Please select an option.

Do you have more than one work address? You can add more from your dashboard after registration is complete.

Select Your Membership State*

Please select an option.

Membership State is based on your work address and is not editable.

Do you want to receive important SMS notifications from your membership state?

What kind of notifications will I receive? • Standard carrier rates will apply

Yes, I want to receive SMS notifications

Please select an option.

1 Personal

2 Education

3 Work

4 Membership Dues

Your ADA membership dues

I want to pay my membership dues

Monthly

Yearly

Please select an option.

Membership Dues

Membership Dues Summary

Monthly

Recurring membership charges

Total recurring$50.00/mo

Amount due today$50.00

Selected Add-Ons

0 selected

Your Name

Current Home Address

Dental School

Residency

Dental License

Work Address

Explore More Add-Ons

Clinician Resources

Washington Advocacy Champion

Practice Owner Essentials

Washington Advocacy Champion

Clinician Resources

Practice Owner Essentials

Membership Dues Summary

Recurring membership charges

One-time add-on charges

Selected Add-Ons

Your Name

Current Home Address

Dental School

Residency

Dental License

Work Address

Suggested add-ons for new members

Clinician Resources

Washington Advocacy Champion

Practice Owner Essentials

Explore optional benefits

Membership Dues Summary

Recurring membership charges

One-time add-on charges

Selected Add-Ons