Membership Registration Form

Please complete the following information to apply for membership to the Maine Licensed Denturist Association. All fields are required. Membership is not guaranteed and is subject to approval. Annual membership dues are $200 plus $100 for each additional clinic you would like listed in the Denturist Locator.

Personal Information:

First Name

First Name :: Please enter your first name.

M.I.

M.I. :: Please enter your middle initial.

Last Name

Last Name :: Please enter your last name

Suffix

Suffix :: Please enter your suffix.

Date of Birth

Date of Birth :: Please enter your date of birth.

Home Address

Home Address :: Please enter your home address.

Home Phone

Home Phone :: Please enter your home phone number.

Email Address

Email Address :: Please enter your email address.

Professional Information:

LD License #

LD License # :: Please enter your LD license number.

Clinic Name

Clinic Name :: Please enter your clinic name.

Clinic Address

Clinic Address :: Please enter your clinic address.

Clinic Phone

Clinic Phone :: Please enter your clinic phone number.

Professional History

Professional History :: Please list your professional history (work experience, lab experience, clinical experience, education, etc.)

What changes would you like to see in our field?

What changes would you like to see in our field? :: What changes would you like to see in our field?

What contributions can you make to our field?

The above information is accurate to the best of my knowledge.

Terms :: Please agree to the terms.

I understand that submitting this form does not guarantee membership and that I am submitting my application for review.

Terms :: Please agree to the terms.

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