ADHA Hands Free Demo 2011 : Page 14

Membership Form Join. Participate. Benefit. Succeed. Call or log on today (312) 440-8900 | http:/ /membership.adha.org Member Information Name Address City Dental hygiene school attended: Highest educational level attained: Circle Your Credential: RDH LDH Certi fi cate Other: State Email Daytime Phone (include area code) Zip State Associate Evening Phone (include area code) Year of Graduation Baccalaureate Master’s Doctorate State: Current License # To qualify for Active membership, you must have been granted a license to practice. Applications received without a license number will not be processed. Membership Demographic Information In an effort to learn more about ADHA members, we would appreciate your assistance with the following information: Gender: Female Male Birth Date: Ethnicity (optional): Hours worked per week in Dental Hygiene: Primary Position (check one): Clinician Educator Public Health Researcher Administrator/Manager Year(s) Issued: Other State(s) in Which You Hold Current License(s): Annual Dues ADHA Constituent* Local component* Assessment** Total $175.00 $ __________ $ __________ $ __________ $ _________ License Number(s): Method of Payment I am enclosing a check payable to ADHA for the amount of my annual dues. (see Total) Please charge my annual dues to my credit card. (see Total) Please enroll me in the Quarterly Payment Plan using my credit card. (see Total plus additional $12.00 processing fee) *Renewing members must opt-into the quarterly payment plan online using your existing membership account. Visit http://payments.adha.org for more information on available payment options *ADHA bylaws require all active members belong to national (ADHA), constituent (state) and component (local area) organizations. Contact ADHA Member Services for correct constituent and component dues amounts (312) 440-8900. **Only CO, CT, HI, ID, IL, KS, OR, WA Dues are not deductible as a charitable contribution for federal income tax purposes. They may be deducted as a business expense. Card Number / Expiration Date Signature I understand that by providing us your credit card information, you hereby agree that ADHA may automatically renew your membership each year by charging the applicable membership dues fee directly to your credit card. Your membership fee will be charged on an annual or quarterly basis according to the manner you have indicated. Please ensure we have updated credit card information so the renewal may be processed. If you do not wish to have your dues automatically renewed each year, you may opt-out next year. VISA MasterCard Send Application to Mail 444 North Michigan Avenue, Suite 3400, Chicago, IL 60611 Phone (312) 440-8900 Apply online at www.adha.org DUES ARE NONREFUNDABLE ACCESS 14 NOV 2011 access

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