To apply for membership online, please complete and submit the following information form.
Name
First
M.I.
Last
Gender
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Date of Birth
License #
Mailing Address
City
State
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Zip Code
This Address is a:
Home Business
Business Phone include area code
Business Fax include area code
Home Phone include area code
E-Mail
Are you a member of another dental organization? NDA ADA ADA Number
Have you ever been a member of AGD? Yes No
Dental School attended: From To Degree
Postgraduate training: From To Degree
Practice Status: (Check all that apply) Solo Associateship Group Practice Federal Services (Specify) Specialist (Specify)
Annual National and State Dues:
Local Component Dues:
TOTAL DUES:
NOTE: After submitting this form, we will contact you by phone to confirm your application information and request your preferred method of payment.