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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