Enrollment Application

If you would like to know about installment dues before you make application for membership please email Kim Roberson kroberson@ncdental.org

NOTE! You will be able to review your information and make changes at the end of this process. Do not press the “back” button or you could lose the information you’ve entered up until now.

Membership application confirmation and your dues invoice will be emailed to you from us via info@ncdental.org. Please make sure this address is not quarantined or marked as spam by your email client.

Join Organized Dentistry
* Required Field
*Date of Birth
/ / (MM/DD/YYYY)
Preferred Phone
No dashes or spaces
No dashes or spaces
No dashes or spaces
Mailing Address
*North Carolina County
*District
Maiden Name
ADA Number
*NC License
NC License Date / / (MM/DD/YYYY)
Pre-dental School
Pre-dental Degree
Pre-dental Grad Date / / (MM/DD/YYYY)
*Dental School Name
*Dental Degree
Student DDS
DMD MD
PhD
*Dental Degree Year
Grad Program Name
Grad School Name
Grad School State
Grad Program Begin Date / / (MM/DD/YYYY)
Grad Program End Date / / (MM/DD/YYYY)
*Specialty
00-General Practice 10-Oral & Maxillofacial Surgery
15-Endodontist 20-Orthodontist
30-Pediatric Dentistry 40-Periodontist
50-Prosthodontist 60-Oral Pathologist
70-Public Health 80-Oral & Maxillofacial Radiology
90-Faculty
Spouse Title
Spouse First Name
Spouse Last Name
Mentoring

 

*American Dental Political Action Committee (ADPAC) is a federated state and federal political committee that makes contributions to federal candidates and committees. Contributions to ADPAC and North Carolina Dental Political Action Committee (NCDPAC) are voluntary and any member has a right to refuse to contribute without reprisal. The contribution guidelines are merely suggestions and a member may contribute more or less or not at all without concern of favor or disadvantage by the association. $50 of your contribution over $135 and less than $550; and $250 of your contribution $550 and over is transferred to ADPAC Federal to support Federal candidates and committees, while the balance remains in the state to support state candidates and committees. Corporate donations will be used exclusively to pay for the administrative and operating expenses of ADPAC. Contributions are not deductible as charitable contributions for federal tax purposes. Federal law requires ADPAC to request the name, address, occupation and employer for each person whose contribution exceeds two hundred dollars ($200.00) or more in a calendar year.