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2012 ADAA Membership Application

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  1. 1. WHO YOU KNOW HELPS WE UNDERSTAND AMERICAN INSUraNCE PERSONNEL DENTAL ® State Association and Our membership includes all ASSISTANTSWE HAVE WHAT YOU NEED: WE’VE GOT EVERYTHING FOR PERSONAL & PROFESSIONAL GROWTH Local Society: dental care professionals in ASSOCIATION Active groups in most states the field, and we work to serve along with many regions and metropolitan areas provide you all of you with programs for your professional growth and ADAA with professional contacts, personal needs. Is For learning, networking, and • Prescription Discount Service Every Type Of community involvement. • Discounted Health Services Programs DEN TAL • OfficeMax Discounts • Schein Uniform Discounts A SSISTAN T EDUCATORS SALES/SERVICE REP Educators are at home at the ADAA too. • Credit Card Programs for those who You’ll receive the twice yearly ADAA Educators’ qualify MEMBERSHIP APPLICATION THERE’S SO MUCH TO CHOOSE Newsletter and a special invitation to be published in • Reduced rates at Choice Hotels the ADAA’s journal, The Dental Assistant. and discounted rates on Alamo and National rental cars 2012 CLINICAL ASSISTANTS ...the backbone of the dental practice. We serve clinical assistants through our numerous CE courses (at special member rates), articles in the INCLUDED IN YOUR DUES: Journal that address all aspects of chairside work • $50,000 professional dental assisting liability insurance in your EDUCATOR and convention topics too. name. Automatically. “The people who make dental • $2,000 of accidental death and ADMINISTRATIVE ASSISTANTS AND dismemberment insurance assisting a profession!” PRACTICE MANAGERS automatically—Up to age 70. Articles of administrative interest in The Dental • Online employment service on the Assistant journal; continuing education at reduced internet. member rates; and, upon request, the ADAA • A subscription in your name to the ADMINISTraTIVE newsletter Business Beat. award-winning journal The Dental Assistant. • ADAA Online 24/7 E-Newsletter. JOIN ONLINE! • Discounts on hard copies of American Dental Assistants Association W W W.ADAA1.COM home study continuing education 35 E. Wacker Drive, Suite 1730 courses. Automatically. Chicago, IL 60601-2211 • Eligibility to participate in ¡SE HABLA ESPAÑOL! ADAA’s Fellowship Program. Phone: (312) 541-1550 • Free continuing education in The Fax: (312) 541-1496 Si usted se siente más cómodo discutir los beneficios Dental Assistant for members only. CLINICAL Toll Free: (877) 874-3785 de la asociación de ADAA en español, llame nuestro numero 877-874-3785 extensiones 201, 211 o 213. • Complete access to ADAA’s online E-mail: Nuestros materiales educativos son en inglés, pero se education library. FREE ADAA Main Site: pueden discutir en español. Continuing Education Site:
  2. 2. 2012 Send payment to:NEW ACTIVE MEMBER APPLICATION ® American Dental Assistants AssociationNOT VALID AFTER 03/31/2012 35 East Wacker Drive, Suite 1730 ®after 03/31/12, check the ADAA website for Chicago, IL 60601-2211the most up-to-date application, discounts Toll Free: (877) 874-3785 Fax: (312) 541-1496apply after 03/31/12. To join online: PRINT LEGIBLY OR TYPE AND FILL ALL APPLICABLE SPACESADAA member previously? (if so, include maiden name, if applicable): Today’s Date:Name FIRST MIDDLE LASTStreet Address Apt.#City State Zip CodeBusiness Phone ( ) Home Phone ( )Cell Phone ( ) E-mailState Dental Assistants Association(if other than the state where you live)Local Dental Assistants Organization (if left blank, we will assign a local where available)NOTE: By jOININg ThE ADAA, yOU ALSO BEcOME A MEMBEr Of A STATE AND LOcAL OrgANIzATION If ONE ExISTS. LOcAL MEMBErShIP wILL BE IN ThE SAME STATE ASSTATE MEMBErShIP. STATE/LOcAL DUES AMOUNTS ArE LISTED BELOw. ThIS AMOUNT MUST BE ADDED TO yOUr ADAA NATIONAL DUES. Please list any credentials:_________________________________________________ LIST CREDENTIALS IN ORDER OF IMPORTANCE. ONLY THE FIRST 20-25 CHARACTERS, INCLUDING YOUR NAME, WILL APPEAR ON YOUR MEMBERSHIP CARD cErTIfIcATION NOT rEQUIrED TO jOIN ADAA.Please check applicable fields: q Chairside q Business Assistant q Office Manager q Educator q OtherchOOSE ONE PAyMENT TyPE frOM OPTIONS BELOw. NATIONAL DUES AND STATE DUES rEQUIrED TO jOINVisit our website for more payment options or call us! ADAA. choose your state from the table below. q OPTION 1 - fULL STATE(S) yEArLy DUES $ 125.00 National Dues/Prof. Liability Insurance DE $6.00 $ State Dues (LIST frOM chArT ON rIghT) AL, AR, KY, ME, MO, MT, NH, NM, VT, WY $10.00 $ Total DC, GA, HI, ID, LA, SC $12.00 -Or- AK, AZ, CO, MS, NC, ND, OK, OR, UT, WA, WV $15.00 q OPTION 2 - SEMI-ANNUAL † CT, MD, RI $18.00 KS, MA, NV, NJ, NY, OH, PA, SD, WI $20.00 $ 77.50 Nat’l Dues/Prof. Liability Ins./Plus one-time $10 IL $23.00 Processing Fee VA $24.00 $ State Dues (LIST 1/2 AMOUNT frOM chArT ON rIghT) FL, IA, NE, TN, TX $25.00 $ Total MN $30.00 † FOR OPTION 2 IN $35.00 1. A $10 PROCESSING FEE AND $10 LIABILITY IS INCLUDED WITH FIRST INSTALLMENT CA, MI $40.00 2. YOU WILL BE BILLED $57.50 + HALF YOUR STATE DUES FOR YOUR SECOND INSTALLMENT q Plaque $20 (optional) - oak laminate & black leatheretteNO POrTION Of ADAA fEES ArE rEfUNDABLE Or TrANSfErABLE l Note: 48¢ of your ADAA dues is not tax deductible l Membership includes a subscription to The DentalAssistant, $50,000 professional dental assisting liability insurance, $2000 accidental death and dismemberment insurance l Membership, professional liability insurance andaccidental death insurance become effective following receipt and processing of application. TOTAL AMOUNT ENcLOSED: Be sure to include state dues in your total.Payment made by: q VISA q MASTERCARD q CHECK(payable to ADAA)Credit Card #: - - - Exp. Date: /Cardholder Name:Cardholder Address:Cardholder Signature:Go to to become a member online.