Membership Application

Membership Application
Annual membership fee:

$100.00 Active Member
$ 50.00 Associate Member
(Certified Pediatric Dentist,
No Specialty License)
$ 50.00 1st Year Pediatric Dentist
$ 50.00 Affiliate Members
No Fee Graduate Student Resident

Make check payable to ISPD

Thank you for taking the time to complete this application.

Please return application and membership fee to:

Ms. May Stern
Illinois Society of Pediatric Dentists
University of Illinois at Chicago
Department of Pediatric Dentistry (M/C 850)
College of Dentistry
801 S. Paulina Street
Chicago, IL 60612-7211
E-mail: maysie@uic.edu

 



Last Name  First Name  M.I. 

Mailing Address 
City  State  Zip 

Office Address #1 
City  State  Zip 
Office Address #2 
City  State  Zip 

Business Phone  Ext.      
Fax Number 
Email Address 

Dental School (Institution/Degree/Year)



If you are applying for affiliate membership, stop here.

Specialty Program (Institution/Degree/Year)



Hospital Appointments/Affiliation (Institution/Year)



Professional Reference 

Name 
Address 
Phone  Ext.     


Do you hold a pediatric specialty licence in the State of Illinois?

 Yes  No


   
Do you hold a specialty license in any other state?

 Yes  No


   
Do you hold a specialty license in any other specialty?

 Yes  No


   
What is your Board Status for the American Board of Pediatric Dentistry?




   
What is your primary focus: Private practice or Academics?



Illinois Society of Pediatric Dentists
M/C 850
801 South Paulina Street
Chicago, IL 60612
312/413-7714