Program Manual - Saint Louis University

Application for American Association of Orthodontists Membership
American Association of
OrlhodonHsls
I, _______________________________ , hereby apply for the following (mark only one box below)
o Active o Affiliate o Service o Student o International Student o International o Academic (foreign-trained)
(see reverse for a list of qualifications for each member classification)
membership in the American Association of Orthodontists and agree to comply ",rith its Bylaws and to adhere to its pledge
which I have read and signed on the reverse side of this application.
Date ___________ _ Signature _____________________ ______ _________ _
Main office or teaching facility
Adill·ess ___ _____________________ _____________________ ______ _
City _ _ __________ _ StatelProvince _______ _ ZiplPostal Code ______ _ Country ____ ___ _
Phone ___________ _ ___ Fax _ ____ _______________ __ E-mail _ _________________________ ________ _
Effective date for this address ________ _ _ _____ ___ Please send AJOIDO and correspondence to: o Home 0 Office
Home
Address _____________________________ _ Spouse's Name _ _ ___________________ __ ___
City ____________ _ StatelProvince __________ _ Zip/Postal Code ______ _ Country _ _ ______ _
Phone _____ _______ _ Fax ____________________ _ E-mail ____________________ _
Satellite office
Address ________________ ____ _____ ___ __________________ _____ _
City ____________ _ StatelProvince ____________ _ ZiplPostal Code ______ _ Country ____________ _
Phone _______ _____ _ Fax ______ ______ _____ __
Date and place of birth _____________________ ___ _ Gender: 0 Male 0 Female
Dental school ______________________________ _ Degree ______ _ Date of completion _ _ _______ _
Orthodontic education received at _ _ _ _ ___ ___ __ _ Degree _ ____ _ _ Date of completion ___ _ _ _ _ _
(Copy of degree or certificate verifying completion of orthodontic program must accompany application. If you are currently a .tudent, list your expected date of
completion and send n letter from your school verifYing your full·time student status.)
Military service (service applicants only)
o Army o Navy o Air Force o Marine Corps o Coast Guard o US Public H ealth Service o Veterans Administration
Rank _____ ____________ _ Datesofservice _ _____________________________________ _ _ _
Other
Are you a member of the American Dental Association? (ADA membership is required if permanent U.S. resident) DYes 0 No
ADA member # ______________________________________________________ (please enclose a copy of your ADA membership card)
If you are a student who is a permanent resident of Canada, check here 0 for a free membership in the Canadian Association of Orthodontists.
Are you a member of the World Federation of Orthodontists (international applicants only)? 0 Yes 0 No WFO # ___ ______ __
Has your dental license ever been suspended? 0 Yes 0 No
Have you ever been convicted of a felony or a crime involving moral turpitude? DYes 0 No
Have you ever been found guilty, either by conviction or admission, of any offense involving the illegal distL'ibution of narcotics? 0 Yes 0 No
PLEASE NOTE: A copy of your ADA membership card (if you are a permanent U.S. resident .. ), a copy of your orthodontic degree or certificate (or a letter
from yom department chair verifYing full-time student status), and membership application fee or first year's dues must accompany this appucat.ion. We
cannot process incomplete applications. Incomplete applications will be returned to the applicant.
If you wish to pay your application fee and/or dues with credit card, please complete the credit card information on the back of application.
Please see reverse side of oppli:cation {or pledge and requirements for membership in the American Association of Orthodontists.
(over) 6/07