Member Application Membership Application Select Membership Category*ActiveAssociateAffiliateLifeFirst Name*Last Name*Dental Degree*Office Address*Office PhoneZip*Employer Name*Office FaxCell 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:
