AMERICAN DENTAL HYGIENISTS’ ASSOCIATION



[pic]AMERICAN DENTAL HYGIENISTS’ ASSOCIATION

Membership Application

Return to: Division of Member Services, 444 N. Michigan Ave., Suite 3400, Chicago, IL 60611 312-440-8900 • FAX 312-467-1806 •

Name (Last, First, Middle Initial)                  

RDH LDH Other:           

Maiden Name (If applicable)

Street Address:       Home phone (include area code)     

City/State/Zip Code:                   Cell Phone (include area code)     

Email Address:      

Dental hygiene school attended:       State:       Year of Graduation:      

To qualify for Professional Membership, you must be licensed to practice dental hygiene.

Current License #:      State:      

(Required)

Highest educational level attained Certificate Associate Baccalaureate Master’s Doctorate

Annual Dues: National Dues $ 185.00, MI Constituent Dues $ 98.00, Local Component Dues $ 10.00

I am enclosing a check payable to ADHA for the amount of my annual dues - $293.00.

Please charge my annual dues of $293.00 to my credit card.

VISA MasterCard Card Number:       -       -       -      

Expiration date:       Name as it appears on the card      

(MO/YR)

Signature: __________________________________________________ Date:     

I want my component dues to be applied to and sent to:      

(Insert component name from map below.)

Dues are not deductible as charitable contributions for federal income tax purposes, but may be deducted as a business expense. DUES ARE NONREFUNDABLE. For questions, call ADHA: 312/440-8900.

ADHA has two dues billing cycles: summer and winter. The summer dues billing cycle begins April 1 and ends September 30. The winter cycle begins October 1and ends March 31. All new members will be assigned to one of the billing cycles depending on the time of year that the application is submitted. Annual dues may be paid by completing the application and mailing it in with a check or credit card information or contact ADHA Make check payable to ADHA and mail it to: 444 N. Michigan Avenue, Suite 3400, Chicago, IL 60611

To enroll in the Quarterly Payment Plan, contact ADHA. (A $3.00 per quarter transaction fee is applied).

For current contact information for Michigan Components please email: joyce@

01 Central

02 Oakland

03 Washtenaw

04 Detroit

05 Genesee

07 Grand Rapids

08 Macomb

09 Saginaw Valley

11 South Central

12 Mideast

13 Southwest

14 Midwest

15 Upper Peninsula

16 Lakeland Valley

17 Northland

18 St. Clair

19 Mid-Michigan

20 Sunrise Side

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