ADHA Membership
Application
Please PRINT this application and send it to:
American Dental Hygienists' Association
444 North Michigan Avenue, Suite 3400
Chicago, Illinois 60611
(800) 243-2342
TYPE OR PRINT (Abbreviate only when necessary)
_______ - _______ - _______
Social Security Number
(Be sure to enter correctly. This
will be your ADHA identification code.)
______________________________________________________
Name (Last, First, Middle initial)
Your Appropriate Professional Credential:
__ RDH __ GDH __ LDH __ Other: ___________
______________________________________________________
Maiden Name (If applicable)
______________________________________________________
Street Address/Apt. No.
______________________________________________________
City/State/Zip Code
(_______)______________________________
Daytime Telephone (Include area code)
(_______)______________________________
Evening Telephone (Include area code)
Highest educational level attained:
__ Certificate __ Associate __ Baccalaureate __ Master's __ Doctorate
To qualify for membership, you must have been granted
a license to practice dental hygiene.
Current license #: ___________________________ State
______
Dental hygiene school attended: ________________________________
State ______ Year of Graduation: 19 _____
Annual Dues
(Call 1-800-243-2342 for constituent and component dues
amounts.)
National Dues $ 155.00
Constituent Dues $_________
Component Dues $_________
(Where applicable. Specific component will be assigned
when application is received by ADHA.)
$_________ Total
$6.00 and $5.00 of ADHA yearly membership dues are
allocated for subscriptions to the Journal of Dental Hygiene and Access,
respectively. Dues are not deductible as charitable contributions for
federal income tax purposes. They may be deductible as a business
expense.
Method of Payment
__ I am enclosing a check payable to the American Dental Hygienists'
Association for the full amount of my yearly dues as determined above.
__ I want to use the ADHA EASY4 Payment Plan through my bank checking
account. I am enclosing 1/4 of my total dues plus the one-time annual
ADHA service charge of $10.00 now. I hereby authorize the American
Dental Hygienists' Association to initiate debit entries to my checking
account indicated below and authorize the financial institution named
below to debit the same to such account.
Financial institution ________________________________________
Branch (where applicable) ___________________________________
City/State ______________________________________________
This authority will remain in effect until 3/4 of one
year's membership dues has been debited to my checking account. I
understand a payment will be debited 3 times approximately every 3
months (depending on the date of receipt of my initial payment and
service charge) for 1/4 of my total annual dues.
Signature _______________________ Date ____________
Please charge the full amount of my yearly dues as determined above to
my credit card. (Complete credit card information below.)
__ I want to enroll in the ADHA EASY 4 Payment Plan. I agree to pay one
full year's dues of _________ (enter amount from Total line above) which
will include constituent and component dues (component where
applicable). I understand that my dues will be billed quarterly (4
times) through my VISA or MasterCard and that a $10.00 annual ADHA
service charge will be included in the first quarterly payment.
__ MasterCard __ VISA
Card number ________________________________
Expiration date _________
Name (as it appears on the card) ________________________________
Signature ________________________________________________
Date ________________________
DUES ARE NONREFUNDABLE (5-96)
Thank you for joining and supporting ADHA. Once your membership
application is processed, you will receive your membership card and
certificate, along with information outlining how to participate in the
programs.
A notification will be mailed to the state and local organization
advising them of your membership status. If you have any questions
regarding membership or any ADHA program, please feel free to call the
Member Services Division at 800/243-2342 and press #3.
