Member Application Membership Application Select Membership Category*ActiveAssociateAffiliateLifeFirst Name* Last Name* Dental Degree* Office Address* Office PhoneZip* Employer Name* Office Fax Cell Phone*Email* Yes, Please include my email in the membership directory Yes, You have my permission to release my email to annual meeting exhibitors Home Address* Home Zip* PhoneFor mailing, please use my:* Home address Office address If applicable, Spouse's name: Dental Degree* Year* Other Degrees: Year(s): Advanced Formal Training: Are you Board Certified?* Yes No Year(s): What year did you become a member of the American Board of Prosthodontics? Are you licensed to practice in Florida?* Yes No Other States: Presently, if you are a part of a dental department in the Army, Navy, Air Force or Veterans Administration, give rank and date of beginning service: Are you a member of the ADA? ADA membership is not a requirement for FPA Membership. However, all members are encouraged to become members of the American Dental Association.* Yes No Please list other dental organizations you belong to:
