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 $45.00

Component Dues $10.00
(Where applicable. Specific component will be assigned when application is received by ADHA.)

$210.00 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 #1.