Transfer Application

Enter your previous state association

First & Last Name - ADA # preferred

Gender

Home Address

Please include area code

Please include area code

Please provide a non-.edu email address

Preferred Mailing Address

Office Address

(Used to determine local dental society)

Please include area code

Please include area code

Practice Information

Is the practice a professional corporation?
Do you also practice at other locations?
Practice type
Are you board certified? (Documentation of board certification is required. Please submit proper paperwork to your local dental society.)

Education

Dental School
Residency

If you did not complete a residency, simply enter N/A

Enter "GPR" if applicable

Leave blank if unsure

Are you currently registered with the NYS Dept. of Education?
Have you been affiliated with dental associations previously?

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Were you ever convicted of a felony or misdemeanor or disciplined by a state board for dentistry, state regents board, other governmental agency, or other dental or professional organization?
Are you currently under investigation by any licensing body, governmental agency, or dental or other professional organization, which could lead to disciplinary action?
Were you ever disciplined or had an application for membership rejected, deferred or suspended by a state or component society of the ADA, or other dental or professional organization?

By submitting this application, I hereby state that I will conduct my practice in accordance with the accompanying Code of Ethics, which I have read. If at any time I should violate the Code of Ethics, it is understood that my membership may be forfeited in the Component Dental Society, ÃÛÌÒÊÓƵ and the American Dental Association. If elected to membership, I agree to comply with all By-laws, Codes of Ethics, and other Rules and Regulations of the Component Dental Society, ÃÛÌÒÊÓƵ, and the American Dental Association. I attest that all the above information is true to the best of my knowledge.

Learn more about member benefits or membership fees.